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^M ^tmarg of 

teRT FREDERICK WARNSHUIS 

July 12. 1909 . Junh 7. 193^ 

TriisyoLOMi wrrH oaums 

FUOU 
OP i< 
niaiciucx CIV 

AIU . 

IK rt» 

LAMS MtSICAL LMRAMT 

tSUND STANromi OMtvHtsnv 



I I. Mr 7 lU^A 






HEATH'S 
PRACTICAL \nATOMY 



n 



BY MR. CHRISTOPHER HEATH. 



A COURSE OK OPERATIVE SURCERV. 

WKIi -JO Plntc* (r(MiUlfitti); 147 Figorra), 'trnwn from Natun* 
by M. I.«v«ill<i mill iHilnuml, and iinmeroiu WoutlnuU. 
(hwnnil BitiUnn. L«nW8VO, 80». 

A MANUAL O^ MINOR SURGERY AND 
BANDAUINCi. 
Miitli Edition. Witli un Kngnting*. Toifi. Syo, it. 

THE STUDENT'S fiUIDE TO SURGICAL 
DIAGNOSIS. 

Sw^on.l Ifrllllon. Foiii. 8vn, 0«. M. 

INJURIES AND DISEASES OF THE JAWS. 

Jaekaoulaii Prim Emy. Tlilnl B<lltli<n. Wltli n Platr niirl 
tSH W.«l Kii)(Tarliigs. 8vn, 1,'j. 

LECTURES ON CERTAIN DISEASES OF THE 

J AW.S. DnUmn-il at tlif Rojral CollaiRC of 8ui:p!«>iiB uf Kni)lnn4, 
1887. Willi (14 IfligTavlligit. 8vo, it. M. 

CLINICAL LECTURES ON SURGICAL Sub- 
jects : ilcHviTpil at Univrralty Colli-gH H-Jsjiital. With 
'J-t Kliffravinga. Fca)>. 8vo, 0«. 



r^ 



HEATH'S ^^ 

PEACTICAL ANATOMY 



MANUAL OF DISSECTIONS 



EIGHTH EDITION 
EBmsn BY 



WILLIAM ANDERSON, F.R.C.S. 

SUROeOK AN'n LKLTURCn OK ANATtmY AT HT. TUOMAJf'S HOHPITAL, 

■•aoFsmoH or ahathhy at tbe royal ArADEUv or arts, 

EXAMIXm n AJfATOMT FOk TlIB ROYAL COLLKOV OF rilVSIrlAMt AND SriOSOaB. 




WITH 339 ENGRAVINGS ON WOOD 




^ 



-,1KNF0RD UNIVERSITY 
•,/l£0;CAL CENTER 
STANFORD. CALIF. 9"' 



LONDON 

J. & A. CHURCHILL 

11, NEW BURLINGTON STREET 
J39S 



± 






J&i^J 



PREFACE TO THE EIGHTH EDITION. 



This Editiou has been aubjected to an extensive revision 
in order to bring it to a level with current teaching and 
the present requirements of the Examination Boards. The 
more recent progress in Topographical Anatomy, involving 
as it has a greatly increased precision of description, 
especially in connexion with the Viscera, has necessitated 
uu almost complete reconstruction of certain sections and 
the addition of new matter to the extent of 150 pages ; but 
the original plan of the work has been carefully preserved. 

The plates of Arteries prefixed to the last three Editions, 
and a certain number of text illustrations, chiefly histolo- 
gical, have beeu removed as superfluous ; but these have 
been replaced by nearly a hundred new cuts, some original, 
and some borrowed from other works. 

1 desire to acknowledge the valuable assistance aflTorded 
by my friend and former pupil. Dr. W. S. Griffith, in 
pMsing the work through the press. 



WILLIAM ANDERSON. 



2, Hahley Stihet, W. 
Attgiitl, 1893. 



y^'ryr, 



CONTENTS. 



Intboocction 



PAOK 

1 



PART I. 

Dissection op thb Akm 8 

The Axilla II 

Thf Fnjnt of the Upper Arm 25 

The Nerve* of the Ann 34 

The Bend of the Elliow 8« 

The Parts about the bicapula 37 

The Back of the Arm H 

The Front of the Kore-arm 48 

The Back of the Fore-arm fil 

The Palm of the HanJ 74 

The Muscles of the Little Finger 84 

The Mascles of the Thumb 84 

The Ligaments of the Scapola 91 

The Shoulder Joint 94 

The Elbow Joint 96 

The Radio-Clnar Articulations 101 

The Wrist Joint 102 

Table of Muscles of Upper Extremity 108 

Table of Arteries of Up|jcr Extremity 110 

Table of Nerves of Dpf»er Extremity Ill 



PART n. 



DlSSKCTinjJ OF THB LBO 112 

The Front of the Thiph 117 

Femoral Hernia 119 

Scarpa's Triangle 129 

Maade* of the Front of the Thigh 133 

Tbe Inner side of the Thigh \%% 



TIU CONTENTS. 

^P PAnc 

The Buttock 14(i 

Tbe Toplitcal Space 15B 

The Back ..f the Thigh 161 

The Hi|> Joint 163 

The Back of the Leg 168 

The Sole of the Foot 17!* 

The Front of the Leg and Foot 191 

The Knee Joint 2<>2 

The TibioKihulnr Articulationa 210 

The Ankle Joint and Articulations of Foot 212 

Tabic nl Muscles of Lower Kxtrcniity 223 

Tiible of Arteries of Lower Extremilj- 228 

I Table of Nerves of Lower Extremity 227 
I PART m. 

Dissection of the Abdomen 228 

The Perinisuni 229 

Posterior Spncc in both Sexes 231 

Anterior Space in tbe Male 236 

Anterior Space in the Female 246 

The Alxlomiii.'il Wull 252 

The An.'itomy of Inguinal Hernia 263 

The Cavity of the Abdomen 273 

The Peritoneum 279 

Peritoneal Pouches 286 

The Mesenteric Vessels 289 

The Cujliac Axis 293 

Deep Dissection of Abdomen 308 

The .\Mominal Aorta 312 

The Lumbar Plexus .H26 

The Viscera of the Abdomen 32H 

The Pelvis, Male and Female Mi 

Rectum and Organs of Generation in the Male 366 

Pelvic Viscera in the Female 376 

The Ligaments of the Pelvis 383 

Table of .Muscles of Abdomen 387 

Table of Arteries of Abdomen 388 

Table of Nerves of Abdomen 389 

PART IV. 

OF THE Bead asd Neck 390 

1 Scalp 391 





CONTENTS. 

PAOE 

Removal of the Brain 400 

The l>un M^ter aiid Sinuses i03 

The I'ogtcrior Triausle of the Neck 41 1 

The Orbit .420 

The Side of the Neck 433 

The Anterior Triangle 437 

The Conituun Carotid Artcr}- . . 444 

The i>ulx;Iavian Artery 451 

I'he Face 466 

Ma»cle» of the Face 471 

The I*lcrygo-iuajtillftr.v Begiou 486 

The Submaxillar)- Region 497 

l>e«;|i Dissection of Side of the Neck 507 

The Prevertebral Region 514 

The Pharynx 516 

The Pahite 528 

The Superior Maxillary Nerve 534 

The Cnvity of the Nose 536 

Meckel')! Ganglion 641 

The Otic Ganglion 645 

The Ear 545 

The Tonfpic 554 

The Larynx 557 

Liuamenb!! of the Atlas, Axis and Occiput 567 

Table of Muscles of Head and Neck 572 

Table of Arteries of Head and Neck 575 

Table of Nerves of Head and Neck 577 

PART V. 

DnBEcnox or the Tbobax 681 

The Mediastinum 584 

The Lungs 591 

The Heart 59* 

The Foetal Circulation 607 

Ureat Vessels of Root of Neck 612 

The Posterior Medinstinom 618 

Ttie Superior Aperture 628 

Articulation of the Ribs with the Vertebnc 633 

Ligaments of the Verlebrse 636 

PART VI. 

IltSStrTION OF THE BACK AND SPlSAli COBD 639 

T)ir Spinal Conl and its Membranes &a\ 



TABLE OF ILLUSTRATIONS. 



!. 

», 
4. 

C. 

6. 

7. 

HL 

». 
10. 
11. 
12. 
IS. 
II. 
IS. 
16. 
17, 
18. 
19. 
20. 
21. 
82, 

n. 

•H. 
•io. 
2fi, 
37. 
SH. 
2!l. 
.111. 
SI. 
32. 



Mammary 01an<I 
Thf AxUU. . . 
UorirontMl Sirlioti ii| Axillii 
D«'|> Pismrtion of A^ill5 . 
Axillnry Arlcrj' iiu>i Drniiclu's 
Diagrrtm of Oroclilal I'lcxux 

NerTr« of the Axilla 

t<u|icrflcinl l)ikM<<-i.K>ti of ihe Arm 
Miuelvti (if the Kroiii of UpptTArm. 
DiA^immutic Stclion of Shoulder . 
lilaf^'Htn iif .\nnt,l<>iiio«<.-> of ltra(^hiAl 
OlHseoifoii of Kioiil of r|i|nir Arm . 
Th<i ISciiJ of the Kll«iw 
I'lm of the Deltoid 
I*nrt8 nbout the S<.'aiJiila . , , . 
Dissection of Huok of I'ppwr Arm 
SeclioM thniii^'h Uppwr Ami , . 
CutKiitoiiH DiHWctioii of Korc-arm 



. I.nsohka 
Orllflnul 

hmurie 

Koniiniv and Itunti 

Origiiiul 

I.uraa 

HlrHfhri'lil Hiiil Li-vpillA 

nintohfulil mid t,i.'viOll« 

. . Boiiaroy niid Krnii 

Atiilerstiii 

. . . , Aiidfr*on 

Hlnchfvld and r^'vciUi^ 

. . . UiiKinal 

. (.'unnlnghiim 

Original 

Hiroohfald and L.-vnill<^ 

aUerfd from HiVamI 

llirsohfeld iiiwl lA'Tidlh* 

, . Honnmr and Dunu 



Sujierficiol DiKniTtion of Korti-Arm 
Hnpcrlioliil Dissect ion of Knjiil of Kortf-arni . Kinu'lifidd niid 1.. 
Uci'p liiKvi rijon of Kon-rtrin Hiid Hand , . Honiuny mid Uonu 
l>i<c|i Diwolloii of Kronl of Koru-ttrm ilimchfi-ld and l.t!vfill(^ 
Suporfioiiil liisM'Ctiou of itack of Korr-oim . illrachfeld and L, 
Siii«TliL-iiil Miihclct, of the Hack of tho Kort'-arni . , Wilson 

I' ■» of tliQ Hack </f the Korvarin Sappi^y 

I f till' Mimoulij-Spiral Nerve Hinckfcld and I.ovvill'' 

Antii,- ul Uiick of Kore-ann . . .... tJripinal 

."Section through Korc-arm. . ntteml frrnu Iti'ruiid 

Section of WrlHt . . Ilcnlc 

Tlif I'alniHr Kuwlii Andrr«m 

Tran^vctw wclion of Hnml .VndiUKon 

lUiition of I'al mar Arches . AmlirrNon 

' ' ':irpal Uone(> liculr 

of KlnKcrs .\ndcr»'m 

.iinv.u-'-i till I iiuiii^i Aiidt*r8(>n 



I) 
13 
14 
17 
20 
22 
24 
2« 

29 
«2 
3& 

3l» 
40 
i^ 
47 
48 
SO 

as 
nH 

tU) 
«2 
«4 
KH 
70 
71 
72 
74 

-e 

n 

78 

81 

82 
85 



COMTBNTS. 



PART vn. 

PAOI 

DiBBKCTION OF THE BbAIN 662 

The Membranes of the Brain 663 

The VesBolg of the Brain 661 

The Base of the Brain 668 

The Exterior of the Brain 677 

The Mesial Surface of the Brain 682 

The Interior of the Brain 685 

The Lateral Ventricles 686 

The Third Ventricle 69S 

The Cerebellum 697 

The Fourth Ventricle 701 

Cranio-Cerebral Topography 706 



PART vm. 



Dissection of tue Eye 



709 



INDEX 



719 



TABLE OF ILLUSTEATIONS. 



PAOE 

I. Mammarr Oland Lnsclikn 9 

S. The Axilla. Original 12 

3. HorizonUl Section f<t Axilla Brauiie 14 

4. Deep I Mssection of Axilla Bonuray and Itcnu 17 

5. Axillary Arlenr and Branclius flriginnl 20 

ft. Diagram of Brachial PlexDS hncas 22 

7. Kenres of the Axilla Hirschfcld and LeveiI16 24 

8. Ba|ierficial Dissection of the Arm . . Hirschfcld and Lcvtilk* 26 

9. II nscleg of the Front of Upper Arm . . . . Boiiamy and Bt-.iu 28 

10. Diagrammatic Section of 8hnulder Andurs<in 29 

11. Diagram of Anustomoses of Brachial Anderson ^2 

IS. Diaaection of Front of Upper Arm . . Hirschfelii and Levc^illi; 35 

18. The Bend of the Elbow Original 36 

14. Plan of the Deltoid CunniiiKliam 39 

15. Parts about the Scapula , . Uripinal 40 

16. Dissection of Back of Upper Arm . . Hirschfcld and l.i>vcill(i 45 

17. Section through Upper Arm nttin-il fiom Ucrnud 47 

18. Cutaneous Dissection of t'ore-arm . . Hirschfcld iiml l/cveille 48 

19. Sa{>erficial Dissection of Fore-Arm .... Bonamy and Itcau 50 
211. Superficial Dissection of Front of Fore-arm . Hirsclifcld and L. '>2 
81. Deep Dissection of Fore-arm and Hand . . Bonnniy niid Beau 56 

22. Deep Dissection of Front of Fore-arm Ilirschfeld and l.cveille fiO 

23. Superficial Dissection of Back of Fore-nnn Hirschfcld and L. 62 

24. Superficial Muscles of the Back of the Foro-iirm . . . Wilson 64 

25. Deep Muscles of the Back of the Fore-arm Sappey 68 

26. Dissection of the Musculo-Spiral Nei-ve Hirschfcld and I,cveillt^ 70 

27. Arteries of Back of Fore-arm Original "I 

28. .Sc<;tion through Fore-ann. aUerril from Bi-raud 72 

19. Section of Wrist Henle 74 

80. The Palmar Fascia Anderson 76 

31. Trantverse section of Hand Anders<jn 77 

32. Relation of Palmar Arches Anderson 78 

33. ttolion through Carpal Bones Heule 81 

84. Diaifmm of BursB- of Fingers Anderson 82 

36. JtuBClcs of the Thumb Andevsuu %u 



xu 



TABLE OF ILLUSTHATIONS. 



86. MuscIcB of the Hiind Wilson 

37. Iiinertion of Musclua ofXbumb Duchenne 87 1 

38. I'almar laterossei of Hand Original 89 

39. l>i>rs«l Interossei of Hand Originnl S9 

40. Attachment of an Interosseous Muscle Duchenne StO) 

41. Lipnments of the Scjn>ula Wilson 82 

42. Section through tlio Shoulder- joint Anderson B6 ' 

43. Section of Elbow Braunc !t7 j 

44. Ligaments of the Elbow-joint Sappcy 98 

45. Ligament-s of tlic Klbow-joint Sap|H;y S>8 

46. Ellxiw-joint from the Front Anger 100 

47. TmnsTcrBO section thnmjjh Elliow 101 

48. U[>(>er I'nrt of Ulna with Orbicular Ligament . . . Wilson 102 

49. Li|{nmentH of the CiiqiUH Sapiiey 103 

60. Section of Syuovial Mi-mbraue» (if Wrist Wilson 103 

51. Triangular Fihro-cttrtihij^'e of Wrist Wilson 108 

52. Diagram of Exit of lilutcal and Hciatic Arteries . . Anderson 113 
o3. Ntlnton's and Bryant's Tests for Hip-joint .... Ori^;inal 114 

54. Diagram of position of Hip-joints Anderson ll-> 

55. Superficial Dissection of the f J pjin Wotxl list 

56. Crural Sheath laid open Wood 121 

57. Diagrammatic Section of Crural Canal Anderson 1 22 

58. Section of the Kemoml Arch W'itsou 123 

Sn. Diagrammatic Scetitin tlirough Femoral JclliacSbeaths Anderson 124 

60. Irregular Origin »{ Obtumtnr Artery Wood 125 

61. Irregular Origin of Ohlurnfur Artery Wood 125 

62. Section of Thigh througli Hunter's Canal .... Anderson 126 

63. Section of Thigh at Level of Hip Braunc 127 

64. Superficial Dissection of Thigli . . . Hirschfeld and Levetlle IHO 

65. Muitcles of Anterior FeniomI Kegion Wilson 1S5 

66. Profunda Artery and Brunches Bonamy and Beau 1-10 

67. Diagram of the rrofunilH Artery Original U2 

68. Diagram of Vessels of Thigh Anderson 143 

69. Nerves of the Thigh Uirschfcld and Leveille 1+4 

70. Section of Thigh at Apex of Scarpa's Triangle . . . Original 14.'> 

71. Muscles of the Buttock Wilson UH 

72. Deep. Muscles of the Buttock Wilson l.'iO 

73. Arteries of the Buttock Henle l.Td 

74. Dissection of the Buttock and Thigh . Hirschfcld and Leveillii l.M 

75. The Popliteal Solace Original 157 

76. Dissection of the Popliteal Space . . Uirschfeld and Leveillii l."i8 

77. Mnscles surrounding Hip-joint Henle lti4 

78. llio-femoral or Y ligament Bryant 165 

79. Ligaments of the Hip-joint Sappcy 167 

80. Superficial Nerves of Back of Leg . . Ulnchfetd and I.,cvcllli 170 

81. Superficial Muscles o{ Back of Leg WiUon 171 



TABLE OF ILLUSTRATIONS. 



Xlll 




runr. 

Arter)f<i of Back of Leg Bonnmy and Bi-tvu 1 73 

Anastomoses nf Tibial Arteries Amlersua 17(> 

IVep Dissection of Back of Leg . . HirHclifeld and Levcill(5 178 
Relation of Parts behind Inner Malleolus . Hirdchtcld and L. 17!> 

Section of Right Ankle Oripinnl 180 

Superficial Dissection of the Sole . . Hirschfeld and Lcveillii IHl 
Sai>erfioial Dissection of the Sole .... Bnnaniy and Beau IM2 

I>ecp Dissection of the Sole Boiiamy and Beau 184 

Deep Nerves of Sole Hirschfeld and LevcilliS 185 

Deep Muscles of Sole 8apj>cy 188 

Deep Di«»ection of Sole of Foot . . Hiruhfcld and I.cveill6 \W\ 

Mu-scles of the Front of the Le^ Wilson liW 

Deep Dissection of the Front of the Leg . HirBchfeld and L. I!t8 

Section of I>eg in Middle altrrntl fruw lit-miid 21)0 

Dunml Interossei of Foot Orifdnal 201 

nantar Interossei of Foot Oriprial 201 

Anterior View of Knee-joint Saiipcy 205 

Poeterior View of Knee-joint Bappey 20"> 

Intcr-articular Ligaments of the Knee Wilson 207 

Vertical Section of Knee-joint Brnune 208 

Posterior View of Ankle-joint Sapj^y 211 

Vertical Section of Ankle-joint Braune 213 

Internal View of Ankle-joint Sappey 214 

External View of Ankle-joint .'^apiH-y 21."> 

Ligament* of the Sole of the Foot SHp(>cy 2I(! 

Section of S\T>ovial Membranes nf Foot Wilson 218 

Lougituciinal Section of Foot Braune 219 

Vertical Section throiiph I'uneiform and Cuboid . . Braune 220 

Piagiammatic Section of t'orinn-um Anderson 2.H3 

Saj>erficial Dissection of Male I'eriiiieum .... Original 23.1 

l>eep Dissection of the Mule Pcrinieum Original 240 

Dipgrara of Superficial an'I DcppTriangularLigaments Anderson 241 

Vertical Section of Pelvis showing Foscins Brnune 242 

A rteries of the Perina;uni Wilson 244 

The Female Perinieum Savage 247 

Muscles of the Female Pcrinieum .Savage 251 

Nerves of the Abdominal Wall . . . Hirschfeld and I^'n-eilld 254 

Anterior Mu-sclcs of Trunk Wilson 256 

Sufierficial Dissection of the Groin Wood 258 

Diagram of the Descent of the Testis Original 2('i0 

Diagram of the Descent of the Testis Origimil 2i1l 

DUffnun of the Descent of the Testis Original 2til 

TransTcrsalis Abdominis Muscle Wilson 2fi3 

IMssection of the Inguinal Canal Wood 2(i5 

Diagram of the Ingninnl Canal Original 2fi6 

DiagnuD of a Scrotal Hernia Origmai 1^% 



XIV 



128. 
129. 
530. 
1.11. 
132. 
133. 
134. 
IHo. 
IHt!. 
137. 
138. 
I3». 
l+(t. 

in. 
\u. 

Ml. 

}*:<. 

UH. 
147. 
I4N. 
Hit. 
I5U. 
151. 
152. 
153. 
164. 
15.i. 
156. 
157. 
158. 
159. 
160. 
161. 
162. 
163. 
164. 
165. 
166. 
167. 
168. 
169. 
170. 
171. 
172. 
178. 



TABLE OF ILLUSTRATIONS. ^^^| 

Diagram of n Conponitn! Hernia Original 268 

Diagram uf an Infantile Hornia Original 2fiH 

.\iTangeincnt of Lumbar A|>oneiirosi!t Anderson 271 

The Alxiominal Wall from within Wood 274 

Median Sagittal Section of AWnnicn Braune 27."> 

Uiagrnm of Vertical Section of rciitotieum . . . Original 2.'<0 

Transrerse Section of I'eiitonctnn Original 283 

I'eritoneum at Ijerel of Fr.rameii of Winslow . . . Anderson 284 

Female IVlvic Organs from above Savage 285 

Parietal Attachment of Ptritoneum Deldpine 288 

Su|)erior Mesenteric Artery Wilson 290 

Inferior Mesenteric Artery Wilson 291 

The Cfflliac Axis Hcnlc 294 

I diagram of .Anterior Relations of Stomach. . . . Anilentoti 297 
IHagram of rostcrior Relations of Stomach . . . Andi-Tson 298 
Tbe liundcniim . . . nitrrrd from Hirschfeld and Leveill^ .300 

S<.'cliou of Intestine Anderson 3t)l 

I'ancreas in titti ii/Irr Hit 3(I2 

Abdominal Viscera from the Left Side affrr His 3(K"i 

The i'orlol Vein Henle 3tHi 

Abdominal Surface of Diaphragm Wilson 309 

AJwlomiual .Aorla and Vena Cava Henle 313 

Diagram of Relations of Kidneys and Sgileen . . . . Morris 320 

Posterior Surface of Kidney Morris 321 

Two Forms of Renal Duct Wilson 321 

Lumbar Plexus Hirsclifeld and Leveill6 325 

Section of Stomach and Dmxtenum Wilson 32!) 

Ca'cum and Ileo-t'a-cal Valve Wilson 3.S3 

Up(ier Surface of the Liver Wilwrn ,334 

Under Sniiace of the Liver Anderson 336 

Rabbit's Liver injected Krey 338 

Diagram of Circulation in Liver Kieman 339 

Section of Kidney Henle 342 

Plan of Structure of Kidney Kolliker 343 

Pelvic Fascia from the Outside Original 347 

Pelvic Fascia from the Front Original ."t48 

Side View of Male Pelvis Original 350 

Side View of Female Pelvis Maclise 3.') I 

Pelvis with Internal lli;ic Artery Savage 3.">6 

Side View of Female Pelvis with Veins Savage 3."i8 

Iliac Arti'ries and Veins Knnamy and Beau .S60 

Floor of Female Pelvia Bavago 361 

Nerves of Pelvis Hirschfeld and I.cvciU6 364 

Inner Surface of Rectum Luschka 367 

Section of Pelvis and Viscera Sappey 369 

Bladder and Urethra laid open Wilson 372 




b> 



TABLE OF ILLUSTRATIONS. 



174. TransvcrFc Section of Ppnis Ori^nal 374 

175. Transverse Section of Testicle Wilsun 374 

17fi. AnntoitiT of the Testis Wilson 875 

177. LonRitudinal Section of rterua and Vagina Henle 378 

17>*. Section of Female I 'el vis «//'•»• Heiile 379 

179. rterns and Apjiendftges Wilson 380 

IW), Lipanients of the Pelvis Snjipey 3H3 

181. Posterior Liintments of Pelvis Bonamy and Bean 385 

IKS. Section of the Scnli tf/'cr t'oirier 392 

|S3. Nerves of the Scalp and Face. . . . Hlrscbfeld and LeveilR' 395 

184. Arteries of the Scalp and Face Henle 397 

185. Diaeram of Lyniplmtic.H of Head and Neck . . . .Anderson 39!» 
IM. iiide View of SinoBCs of Skull . . . Hirschfeld and Levcilli!- 404 

187. SiniiK-s and Nerves of Base of Skull Orijrinal 406 

tM. Dinirram of Cavernous Sinus Original 408 

1*9. I)ia(fmm of Nerves of Cavernous Sinus Original 409 

19<). So [icrficial r>is."«ction of Triangles of Neck . . . Originiil 413 

191. Muscles of Side of Neck Wilwn 41.'i 

192. Diagram of Brachial Plexus ff/<rr Lucas 419 

193. The Nerves of the Orbit Hirschfeld and Lcveilli'' 422 

194. The Vessels of the Orbit Hirschfclii nnil Levcille 423 

195. Side View of Nerves of Orbit . . . Hirschfeld and Levcille 42.') 

196. The Lenticular Ganglion Hirschfeld and Leveille 42f! 

197. Arteries of Orbit from outer Side . . Hirschfeld and Leveille 427 

I9»». Scheme of Circulation in Kye I>ebert 428 

l99. Muscles of the Eyeball Wilson 4,30 

JOO. Frontal Section of Orbit Merkel 432 

201. Diagram of Veins of Head and Neck Anderson 434 

202. Transveree Section of Neck Brnune 440 

»W. Muscles of the Front of Neck Wilson 442 

»4. The Side of the Neck Orisrinnl 445 

li>5. The Carotid Artery Anderson 447 

Ins. The Right Subclavian and its Branches Anderson 452 

2"7. An8rtomo«e»i of Subclavian and Carotid Arteries . Anderson 454 
Jiw 9ih. liilh. and lllh Nerves of Bight Side . Hirschfeld and X.,. 457 
2119. 9th. 10th, and 1 1th Nerves of Left Side . Hirschfeld ami L. 460 

JIO. Diagram of Cervical Ganglia Original 4fi3 

Sll. Thyroid Body and its Relations Anderson 4(!5 

IIS. Appendages of the Kyo Wilson 4fi7 

SIS. Section uf Upper Kyelid Meckel 468 

114. The Pinna and its Muscles Arnold 469 

115, The Pinna and its Muscles Arnold 470 

Jl*. Muscles of the Nose Arnold 472 

217. Masclos of the Face Wilson 473 

SIM. Arteries of the Face and Qead Original 477 

JI9. Kcrres of the Face Hirschfeld ftnil LeveiWt \%0 



TABLE OF ILLUSTRATIONS. 



I 



PAOK 

220. The CuUiieous Nerves of the Head and Neck . . . Anderson 482 

221. Kibro-Cartilagea of Nose Wilson 4Su 

222. Fibro-CiirliUpes of Nose Arnold 485 

223. Pterygoid Muscles Wilson 188 

224. External Lateral Ij'gamcnt of Lower Jaw .... Wilson 488 

225. Section of Ti'iiiporu- Maxillary Joiut Wilson 4lS9 

22li. Internal LatornI Ligament of Lower Jaw .... Wilson 4H9 

227. Internal Maxillary Artery Original 492 

228. I'tcrygo-MaxilUry Region Hirschfcld and Leveille 494 

229. Inferior Maxillary Nerre Uirschfcld and Leveille ^!•C 

230. Nerves of the Tongue Hirschfeld and Leveilk' .'KW 

231. Styloid Muscles Waion 503 

232. Lingual Artery and Branches . . . Hirschfeld and I>cveillu .'>04 
23.1. Vertical .Section of Tongue in nitii Anderson 505 

234. Otic Ganglion and Tym(mnum . . . Hirschfeld and Leveille 508 

235. l>iep Vessels and Nerves of Skull . . Hirschfeld and Lcveilici 51U 

236. rrcvcrtcbral Muscles Wilson 515 

237. Dissection of I'haryox with Vessels and Nerves . . Original 518 

238. Diagram of ilth.lOth, Iltli, 12thand Sympathetic Nenes H. A: L. 520 

239. Bide View of Muscles of Pharynx Sappcy 524 

240. Pharynx Uiid open Snppey 626 

241. Posterior Wall of the Pharynx Luscbka 527 

243. Muscles of the Palate Original 531 

243. Section of Eustachian Tuljc I'oiricr 532 

244. Superior Maxillary Nerve .... Hirschfeld and Leveille 535 

245. Outer Wall of Nasal Fossa and Pharynx Meckel 538 

24t>. Meatuses of the Nose Wilson 539 

247. Nerves of the Nose Wilson 540 

248. Meckel's Ganglion Hirschfeld and Leveille 543 

249. Outer Wall of Tymimnum Poirier 547 

250. The Ossicula Audit us Wilson 547 

251. Inner Wall of Tym|ianuni Poirier 549 

252. Scheme of Auditory Apparatus Poirier 552 

253. Section of Cochlea Wilson 553 

264. Vertical Section of Cochlea Wilson 553 

255. The Tongue Wil.ion 554 

866. The Under Surface of the Tongue Merkel 555 

257. Posterior View of Larynx Sapjie^' 559 

258. .Side View of Larynx Sappey 559 

259. Vertical Section of Larynx Sappey 5(>3 

260. Anterior Ligaments of Atlas and Axis WiUou iiCtS 

24il. Posterior Ligaments of Atlas and Axis .... Wilson 568 

262. Occipiio-Axial Ligament . . Wilson 570 

263. Cruciform Ligament of .\t las and Axis Wilson 570 

204. Section of Superior Mediastinum . . . Anderson and Mokins 585 

265. Section of Superior Mediastinum Brauae 586 



< 



TABLE OF ILLUSTRATIONS. 



XAll 



2«fl. 
2t;7. 
266. 
SG9. 
270. 
271. 
272. 
273. 
274. 
27.1. 
276. 
277. 
27«. 
2711. 
»>W». 
2X1. 

2S-1. 
2X3. 
2SI. 
2S.1. 
0*6. 
2S7. 
23<S. 
2W. 
291). 

292. 
2'«. 
29t. 

«»:.. 

2»7. 
IHK 
2W9. 

<tiiri. 

S(11. 
302. 
303. 
.<N)I. 
.1<V.. 
.tllti. 
307. 
30H. 
.IIW. 
310. 
311. 
II 



PAIIK 

Dingrom of Section of Thorax Oriffinal r>87 

The Heart and Lungs VVil«in 590 

Inner Aspect of Right Lung. a/tfr Uh tm 

Inner Asport of Left Lung aftrr His flflS 

Diagram of Heart in hUh 59.j 

Right Side of Heart laiJ open Wilson .i99 

Left Side of Heart laid open Wilson 803 

Section of Heart at level of Valves 8ibson 6I)4 

Attachment of Mitral and Aortic Valves B05 

Diagram of Ftetal Circulation Wilson (iOO 

Heart and Large Vessels Bonamy and Beau OlO 

Median 8.igittal Section of Thorax Branne fill 

9th, loth, and llth Nerves of Right Side . Hirsehfeld and L. fiH 
9th, 10th, and Ilth Nerves of I/cft Side . Hirsehfeld and L. UKi 
Course and Termination of Thoracic Duct .... Original fi20 

Veins of the Trunk and Neck Cruveilhicr fi22 

Section of an Intercostal Space Anderson 825 

Sympathetic Chain in Thorax Wilson B27 

Section of Superior Aperture of Thorax .... Original ti28 

Upper Surface of Diaphragm Original dSO 

Trachea and Bronchi Aeby 631 

Anterior Lignmcnt,<i of the Ribs Wilson 034 

Ligaments of the Bibs Wilson 634 

Transverse Section of Vertebra and Uib Quain 635 

Posterior Common Vertebral Ligament Wilson 036 

Livamvnta Suliflava Wilson (i3B 

Superficial Muscles of the Back Wilson 640 ^m 

Deep Muscles of the Back Wilson niii ^H 

Suboccipital Region Origiunl t>4U ^| 

The Nerves of the Back Hirsehfeld and LeveilU- 652 ^| 

Transverse Section of Spinal Cord Hirsclifold arid Leveille 654 ^^ 

The Spinal Cord Hirsehfeld iiiid Leveilli- 657 

Diagram of Trad? and Colnmns iif Spinal Conl Gowers 65S 

Diagram of Fibres of Norvc-roots Schiifer i;5!l 

Cauda Equina Hirsclifeld and Leveilli^ 660 

Arteries of the Kraiii Wilson 6lii; 

Scheme of Distribnlion of Cortical Branches of Cerebral Artcr.v 667 

Ditto from Outer Side 667 

Krontal Lobe and Island of Reil Turner 6611 

The Base of the Hrnin Hirsehfeld and Leveillr 673 

rp|ier Surface of Central Hemispheres Daltim 67M 

Lateral Views iif Coini>lnti(ins Tlmne 6T!f 

Inner Surface of Central Hemisphere Thatie flHl 

Lateral Ventricles of the Hrain . . . Hirsehfeld and Leveille ti.su 
Descending Cornu of Lateral Ventricle . . Hirsehfeld and L. OIK) 
Section through Tr.insverse Fissure ... Anderson 6M2 

I 



XVIU 



TABLE OF ILLUSTRATIONS. 



PAOK 

312. The Velum InteTpositom Original 693 

313. TranBreree Vertical Section of Brain Clark 694 

314. Third Ventricle of Brain Hirschfeld and Levellli 696 

315. Fourth Ventricle of Brain .... Hirschfeld and Leveilli 699 

316. Under Surface of Cerebellum . . . Hirschfeld and Leveill^ 700 

317. Vertical Section of Brain Hirschfeld and Levcill^ 701 

318 Diagram of Floor of Fourth Ventricle .... o/i!<?r Thane 702 

319. Section through Pons Varolii .... Stilling and Schwalbe 703 

320. Section of Medulla Oblongata Schwalbe 704 

321. Section through Olivary Body Schwalbe lOH 

322. Cranial Topography Anderson and Making 707 

.323. Longitudinal Section of Eyeball H. Power 710 

324. Choroid Coat and Vasa Vorticosa Arnold 712 

325. Section of Ciliary Muscle Jevans 713 

326. Choroid and Ciliary Processes Wilson 714 

327. Crystalline Lens Wilson 715 

328. The Optic Disc Jaeger 716 

329. Section of the Retina Sohnltze 717 



MANUAL OF PRACTICAL ANATOMY. 




INTRODUCTION. 



Br Practical AnuUmiy is meiitit llie study nf Amilomy \iy diswction 
ot' tlie iteail IhkIv, in contnulistinctioii tn Di-st-riptive Aiiutomy, 
taught liy li'ctiin'-^, diagnuiiR, iiiul i>n;imnition.-<. 

In iliNwctiiig, there aiv fuiir principal objects to be constantly 
bomc in uiiml hiy the xtiKlent : — 1 st. Thr iniiiri'ssidii on the memory 
of the fiwts of general anatomy tau^jht in tin; brtliires. 2nd. The 
Ktudy of those yiarts of the bcicly more especially concemeil in surgicrti 
affections and oi)eniti<>ns. 3nl. The cilucntion of the sjcnse nf touch, 
and of the hand in the uxe of instniiiient-i ; and 4th, the education 
of Uie eye in the knowledge of the several stmctures of the body, in 
various p<l^ition■i, and \inder varying ciniiiniatniices. ll is to n8.si3t 
the student in tlie.se re(inir<!nii'nts tliiit the fnllo«in^' work is de- 
cigned ; and every effort has been made to juvsciit the facts of 
Aiiatomy in such n manner that they may In? most e.isily gnu^ped by 
the mind and ivtuined by the memory ; it will be found alsn, that as 
far as is lomjiatible with a work of the kind, attention is drawn to 
those point" whii.h have especial interest in the priutice of niedi- 
cijie or surgery, and directions are given for the jierformance of 
many operations wliich do not seriously interfere with or injure the 
dissection. The e<lucation of tlie eye is a gradual and teilious process, 
but oue which is pretty certain to lie satisfactorily acconiplished if 
tlie ttudent do but use his hands properly, and therefore a few words 
on the manual part of dissection may not be out of place. 

First, as to the INSTRUMENTS miuisite for di.ssection. A ease 
containing »i.v gcaljwls, two pairs of scissors, a pair of dissecting 
forceps, a set of chain-hooks, a blow-pipe, atnl a jirobe, will enable 
the student to make all requisite dissections, supposing that lie is 
tUuwed the ii^e of a saw and chisel in the (iissectiiig-ruotu. 

U. B 



4 




SCALPELS for dissection are made of two j)rinciiml slinj)€8 : in 
one tlie edge is bevelled to the point, the liock being i-tniight ; 
in the other both bnclc and edge are bevelled to ii jii)int midway 
Iwtween the two. The hitter form is jirefernble for most ituqiows. 
The bliule should not \>e more than an inch and a linlf long, and 
never double-etlged, but the material of which ihe handle is eim- 
titnicted is a mutter of iiidift'ereiicc. For all oidinajy dis^secliiin it 
will be found most touveuieut to hold the gcalpel like a pen ; but 
for cleaning the filscia otf muscles, and folbuving out small ncrvesi, 
it is better to hold it reversed, so that the back of the knife may Iw 
against the tissue which is Ui be preserved. In making thi' first 
incision through the skin of a limb, or in any otlier jmsition 
where a long incision is rei[uiTed, the knife may, with advantage, 
be held under the hand, by which the wrist has more idny, and 
the student has the ojipfirtunity of practising a mode of Imlding 
the knife which he will tind ver)' useful when openiting on a 
living body. 

The FORCEPS should be broad at the exlivmities and coai-sely 
serrated, so that it may retain a firm hold on small jiortiotis of 
tissue. It is very important that the foreejis ahouhl not be too 
strong in the sjuing, for in that ca.se its use becomes bo fatiguing to 
the hand that it is impossible to continue it for any length of time. 
It is also imiiortaut to luscertain that the jHiiuts do not separ.ito 
when the blades are pressed furtibly together. The fircejis should 
be held lightly between the thumb and the first and second fingers 
of the left hand, which may be steadied by resting the little finger, 
on a neighbouring jMirt. 

The CHAIN-HOOKS .should be strong, and bent in the direction 
of the thickness and not of the breadth of the steel, as in the latter 
case they are liable t*j be unbent under any considcndile strain. 
Care should be taken that the chains are firndy linked, and that the 
ceutml ring is sulficiently stout to bear any foixe that may be 
applied to it. 

The SCISSORS should be large and strong. A curved pair will 
be found very useful in preparing the ligaments. 

SOUNDS and STAFFS for iutro<lucti.in into the bladder are 
found in most dissecting riKims, together with SAWS aiid other 
large tools re<iuisite for dissection. 

The Btnrlent will do well to 1>ear in mind that he will probably !«• 
called upon in after-life to ujiemte on the living body, and that the 
only true preparation for the task is careful dissection ; he should, 
therefore, as far as possible, conduct all his dis.wctionB as metbixHcAlly 
and with as much care as if openiting on the living body, and by this 



i 
* 



INTRODUCTION. 



I 






means he will do much to tit himself for his duties as a practio 
suT^^n. 

The SKIN consists of two principal kyers, the true skin 
ilerma, and the scarf-skin or ejiidermis. lu the dcml brnly, if at all 
decomposed, the epidermis or cuticle is easily sepanited, Imt it should 
be carefully pre-^erved during the dissection, iis it prcvt-iiLs the sub- 
jacent parts frt>m drying. In removing tlie xkin, the firi-t incisions 
should be made at once through its wliolu tliickness, and a comer 
being held with the forceps, the knife is to be carried with a sweep- 
ing movement beneath it, the t-d^v being tuwanls the skin and the 
liack to the fasciii, which sbould be left smooth and uniforra. The 
under surface of skin neatly reflected is white, and the tissuQ 
beneath it more or less yellow. 

The SUPERFICIAL FASCIA consists of loose areolar tisani 
containing more or less fat. It contains tlie superlicial blood- 
v«!!«cla, nerves, and lymphnticj>, and may in some ailimtions bctH 
divided uito two layers. ^M 

The DEEP FASCIA is a more or less dense librous structure, 
usually white and glistening in appearance, lyin;,' beueiith the 
luperticial fascia, closely invcitin;,' the musculature of the limbs, 
anil sending inward.H deep intermuscular iirocesses or septa, smne of 
which are strongly attached to the bones. It forms sheath* for the 
niuKles, and gives attachment to muscular fibres. In some parts it 
may be subdi^-ided into superficial and deeper lamina>, its in the 
Dock Olid thigh. 

In cleaning MUSCLES, it is essential that the fibres should be 
made tense by moving the limb or applying the hooks. A muscle 
should invarialdy be cleaned along its filires, the dissector beginning 
at one edge and advancing sti'aJily to the other, luid thus reltecting 
a complete layer of fascia; the knife being held with the back to 
tlic muscle, to avoid injury to it. The attachmeiiLs of a luuscle 
(origin iind insertion) should always be most ciiivlully followed out, 
tnii slU'lied on the separate bniies ; but it is important also to clean 
the fa«oia from the whole length of the muscle, or it will soon look 
dirty. A muscle shuuld be divided, when neceHsary, midwaj 
b«twe«n its origin and insertion, so tiiat these important points 
may be preserved for further reference. 

The action of the various SfU.S(jLES may be roughly but very 
aiefully investigated in the course of dissection. A'* a rule, the effect 
of th« cimlraction of a muscle, upon any articulation over which it 
pasMM, may be estimateil l>y ascertaining what movemeuls at that 
joint apjiroximate the origin niid in*rtiLin of the muccle ; but where 
thv connection of a muscle with a pulley or aesaiuoiil Ixiue \w!Lia 

n i 



INTRODUCTION. 



to an alterntinn in the course of itH long nxis, the cnlculation miii 
be made from t!ie j»oint at which the line of action is bo chnn^ed. 
Where a nmsclc jiasoes over more than laie Joint, its eifects u])on 
each articulation must be tested »cpnrjitely, ami it sLonhl Ije seen 
in what way those effects are modified by changes of position in the 
other jointii concerned. 

The niusctea may act : (1) as joint motors causing variou» altera- 
tions in the jHwition of the bones (flexion, extension, al«luction, 
adduction, rotation inwnrtls and oulwanlH, &c.) ; (2) as dilators or 
constrictors of the various apertures of the l>ody — mouth, anus, 
palix'bral fissure, &t'. ; (3) a.s iHl.'itors or constrictors of the tlionicic 
and abdoniino-jiclvic cavities ; (4) as motors of soft parts — skin, 
mucous and synovial meiubmnes, &c. ; (5) as tensors of deep fasciw, 
OS in thfthi^h ; thus probably aiding the circulation in the muscles. 

The influence of gravitation upon muscular action i." very con- 
siderable. In certain ciL«es movenients of flexion involve a pi-e- 
doniinant exertion of the extensor muscles, and firf rmid. Thus in 
Ivendiiig forward the body at the hips while in the standing position, 
the niovenu-nt having lieen initiated by the Hexors, the extensors 
come intf) ]i!ay to restrain and regulate it ; i.e., to lower the trunk 
to the degree and at the rate required. 

The ARTERIES of u subject are u.^ually injected, and it is 
impomible to follow out all the minute branches without this assist- 
ance ; but an opjiortunity chould be taken by the advanced student 
to repeat his dissection upon an iininjecte*! subject, in which the 
appearance of the parts iniire closely resemble." that of the living 
body. 

Tlie VEINS may be divided into sujierficial and deep, the 
former nuining in the eujierticial fascia, the latter accomjianying 
the arteries. The two sets of vessels are united by communicating 
branches. Nearly all the arteries of the limbs are ncconiimnietl bj- 
paired veins (vriirr romiie^), the exceptions to this rule Iteing the 
coninuin femoral and the upper part of the axillaiy arteries. In 
the head and neck the veins are usually single, and someliuies do 
not lie in close relation with the arttriea. 

Tlie LYMPHATIC'S as a rule accompany the veins and like the 
hitter fonn two gi-oups, superticial and deej), which inter-coni- 
municatc through apertures in the deeji fiuicia. 

The main trunks of the NERVES and their principal branches 
are readily followed out, but tlieirnu'nute nunifications re<juire more 
time and labour for their dissection than a student can usually 
afford to bestow u]Hin them. 

The BONES sliould be frequently referred to in the course of the 



4 




I 

i 



INTRODUCTION. 



dissection, in ortler tluit thi-ir relation to the muscles, fascia;, liga- 
ments and other structures may be tlionjuj^lily understfloil. 

The student ghoulil bear in mind that his manual labour is only 
a part of his duty, and will be throw-u away utiles^ he at the same 
time study the description of the jmit upon which he is engaged ; 
he therefi)re should not catry the dissection of his [>:irt ho far that 
he cannot learn its dcBcriptiun ou the Riune ilay, and at ih< mhjr.H ; 
*ud he Hhould if possible it-jjemse the description in tlie evening, 
and always on the next morning, beforu carrying the dissection 
any further. 

In order to preserve a part, it i« essential that the dissector should 
bitoiielf secure the skin around it with n few stitches, and WTap it 
with dam]) or oile<l cloths. These may be di]p|>cd in some preservative 
volution, or common salt may be gnited tinciy over the part. This 
I*tter, however, destroys the colour and smooth appearance of the 
itnictures. A <li*8ectcd part should be sponged over daily, when it 
U uncovered for fresh dissection. 



6^' 




PART I. 



DISSECTION OB' THE ARM. 

[The Student ii requetUd to read On " Introduclioii" before commencing 
tJu l)uH<iioii, unless he has done to <m a previous occnrion.'] 

Bkfoue beginning the dissection, the BtnJuiit shoitlJ make Itiniself 
fully ac«iuaintf<l wilb the external configuration of the part imd the 
relations of surfaie-markings to deeper structures ; and il he has 
already di«8ectc<t this region, he should make the incisions necessarj- 
to expose the principal arteries, netres, &c., in tlie positions in 
which they are nsnally suhjecttd t<i operatinn, taking caie not to 
distAirli tiic tissues unnecessarily, and to stitch up the iuciaiuna 
without dtday. 

The cur\ca of the elnviflc are generally seen with ease ; but the 
linger slmnld lie curried along the bone to note any irregularity 
denoting ulil fracture, ami to trace its articulation with the acnmiion 
prtness of the scajmla, wht're the outer end of the bone usually 
ovenides the acromion and may fonu a niarkeil jironiiiieuce. The 
acrvmto-daneiilitr joint Jisr^iirc runs in a sagittal direction, and lies 
vertically above the middle of the upper extrennty of the humerus 
when (he hand is siipinated. Tlie ttenio-davicular joint should also 
be examined, niiil if the ann is freely moved, the extensive range of 
motion in the articulation will be belter appreciated. The promi- 
nence of the acromion is best felt posteriorly, and the sulwulaneous 
surface of the spine of the scapula continuous with the corresponding 
Burfac* of the acromion should be traced as far im the external angle 
of the basal triangle. 

The development of the vmmmary region varies according to the 
8CX and age of the subject. The advanced student should notice in 
a female subject the condition of the nipple and itK surrounding 
areola^ as indicating jirevious pregnancii',>i or the contrary, ami 
he may advantageously ])ractise removal of the bix-ast by two 
ellipticjd incision.6, one above, the other lielow the nip])le, taking 
great care to remove the whole of the breast, and not to leave ajiy 
issue attached to the skin or the deeper structures. The 



SHOL'LDEll AND AlOI. 



even in the male. It lie* 
il njinco, but in the feoiale 



pouticiD i'( the i>i]i|il<! raii 
Uin«t rniuiiKiiily over the 1 
ilk ufU'ii lit ik luwer leVL'l. 

The rouniluesii of the front of the SHOULDER will be found to 
tlejii-nil up<iu the projt^ction of the fteail of tins hiinuriu Ijeyoml Ihf 
iK'ny iirch formed almvc it by thi* ucruniion anil comi^o-iicromittl 
li.'xiiK-nt, anil in a thin fiuUjoct the heiul of tlxi buna and the 
liKijuinl griMive miiy lie rnulily felt when the una i» rotiUnl out- 
ttiir>l>. Clotic to the inner nide of the hviul of the hiimnrug and 
iiiimediati'ly below the clavicle, but jirojecting forwuid* and outwarvi* 
to u jjliiiii' anterior lo it, (» the eontmiil prwtJK, nnil the relation of 
lliean ImiUi-.> to each otIieT xhoiild be cnrefiilly olwerved. In ii niusculur 
subject, a lone, trianjjiilur ^.toovp or (lim]>le, thr iitfriictiirifiiliir /mm, 
> [H)int niurku \' nun In-tweirji the upper piirta of the 

•i Miiil the jHi!. i..r ; luxl H linear furrow, exten<lin); 

'loui neur the uiiiit end of ihe cliivlcle, ovokxionally marks 
I ri between the clernul «nd cli»vicuh\r (ibres of the lutter 

uiUM-le. tiy liftiii){ the urui and driiwiii;; it from the boily, the 
unti-rior and po«lerior liouuiluries of the lu-itla will be mode promi- 
milt, ami the faM'ia cxtemling from one tu the other will tie put 
<)it the ntrcteh no that the linger cannot be pushed into the oniipit ; 
wheir';i> it the iinii in bniught to the i>ide the fascia is re.laxeil, and 
the fiiig»i will n-oilily fwl thi^ head and neck of the hiniieruH, with 
llie unM vcA-els ami oervoi to their inner hiiie, lunl internal to 
ugoin the wall of tlie thorax, with probably Home lymphatic 

I'lie liKt/u miiKcle forms n prominence on the fwnt of the arm, 
nnii the liracliiat ttrienj and iiifilian nrrrt can be tniceil along it» 
inner iMmier to the licnd of the elbow, and the ilmft of the humeruit 
ciui 1n' r«-ndily felt. The jio^ition of the cnTarn-hTachUilu may be 
iR-en (•II the inner »>ide of the arm in a muncular subject, and on the 
outer «ide a huIcim cjjntiMiionding to the insertion of the dflt-ml, and 
(ri'.w Uiia the convexity of the «ul>cutaneuu» portion of the bruchhi- 
li> uuticun, between the bicejM imd triceps. The titpinntor hmijtu \» 
wen rro-wiiig tile hiwer purl of the brucliiulis auticuK to rt^auh the 
out<;r nlde of the front of the anil. In front of the elbow u a 
hollow, i-orii!>jiondiug to n »\mqk Wtween the supinator longus and 
piiiiinloi- ! ]i. ati), and occasionally the tujieTlu-ial vtiii$ 

"iMti.l .11! iv, in wliicli ease Venesection fhoulil l>e pnictwc«l. 

mil ritmliiU of the hunierun ami its relation to 
iif llie iiinu xhould be olweived, ami the ulnitr 
uern can Iw felt l>etweeu the two jmint* of bone. The rouudetl 
ettmta! emuliilf, with the ridge leading tu it, L< dinlinct in moot 



8 



DISSECTION OF THE ARM. 




» 



subjectf), and, immediately below it, the lumi of iId- mliits, which 
slioiild be rotnted, in order that it* nilutinn to thi; cumlvlu may 
be better npprecinteil. The ruuiided [lohterior surface of the ana 
i» formed by the Irirept iiiusLde. I 

In the FORE-ARM the nulius aui be but little felt, except at its lower 
extremity; but tiie olecmmm jirocexs .iiul shar]) posterior margin 
of the ulna are always to be recognised, even iu very muscular 
subjects. The tendon of the biwps may be felt pussin;; to ita in- 
sertion. It should be observed thai the ulna is the more prominent 
of the two bones at the wrist, whilst the end of the radius extends a 
little lower down than that of the ulna ; and the styloid j>roce»» of 
each can be ivadily distinpuiHhe<l. The tendons of the fifxor airpi 
railiatu and JUjor cnrpi ttlnariii are usimlly prominent, and siTve as 
guides to the riidinl and iiimir ar^rlV,«, which may l>e telt (if injected) 
to the outer, or radial, side of each leiulou. In front, below the 
nulio-carjial joint, may l>e felt the project iiin of the jiisifiirm b<ma 
on the ulnar side, and, less distinctly, that of the tulicrile of the 
scaphoid on the radial side. Behind and on the outer nide may be 
traced the exteni^or tendons of the wrist, lingers, and thundt. In 
the HAND the inrtucurpus and the phataiiyct! are to lie cvamined, and 
the advanced student may advantageously nui]>ut4ite one or two 
fingers (middle or ring). It is to be lunie in mind that the trans- 
veree markings, on either the jialmar or dorsal a-^jject of the fiufjers, 
form no guide to the articuhitimis. In the case of the mi-laiar|)0- 
phalangetd joints the line of urticulntioii is alM^ut three-iimirters of 
an inch on the proximid side of tlie web. When the tinker i-s bent, 
the prominence at the jirticnhition is due to the pri>xinud bone, 
and the joint i» distal to that point. The best rule, iherefore, in 
amputating through the inter-iihalangeal (uticuhitiouB, is to Uaid 
the phalanx which is to be removed to a right angle with tlie one 
above it, and to iiegin the incision on one side at a point midway 
in the thickness of the upper jihalanx, and cut transversely to a 
cori-esponding jwint on the opjwsite side. 

The limb should be cari'fully bandage<l from the fingers to the 
middle of the upjier arm, n:id only uncovered as far as may be 
necessary in the jirogre.is of the dissection. 

[The ann being drawii nvviiy from the side, an incision is to be 
made half an inch to one side of tiie median line of the stenuim in 
its whole length, anil is to bi; joined at right aiigle.H by another 
running along the whole lengtli of the chivicle to the acromion 
process, thi-nce in a vertical direction half-way down the npjier 
arm. and tlieu across the inner a<-pect i.>f the arm as lar as the level 
of the jioslerior fold uf the axilla. Another incision is to 1>e made 



THE MAMMA. 



9 



tnuwvewely from the ensiform cartilage, find laiwt be carried lieyond 
the jjogterinr fold of the iimipit. The large fliip of skin thus marked 
out 18 to Iw reflected tnwnids the arm, the dissector on the rishl side 
U'Kinning ut the lower end uf the steniuiii, and un the left side at ita 
Hjiper extremity.] 

Beneath the Kkin in the subcutaneoue fascia, which i« often very 
fatty. The nianiuia will also be exposed in the fi-niale, or its 
Tudiment in the male subject, and an incixion may l>e carried 
orotind the nipple so as to leave it attached to the ^'tauil in the 

Fijr. 1. 



>^ 



fonner. In a well-developed body thfi fibres of the platysmo 
nyoides may be seen arisinj; from the fosoin Iwlow the clavicle. 

In the female tlie Mamma, or breast (Fig. 1), is a yland of verj- 
variable bulk lying upon the |,Teat pectoral muscle, from which it is 



Fig. 1. — Diasection of mummury gUnd (after Luschkn). 
Subcutant-oUH fnt Ineiili. 



I. ManiilU, with orifices of Ucti- 

f«rx>u> ducts. 
i. Areola. 
3. Ampulla of duct. 



£. Ai'ini of lacteal gknd. 
6, Gland loculi. 



10 



DISSECTION OF THE ARM. 



•uatjid. ^* 



Bcparatctl by a <iuantity of lnose cellular tissue. Its base is tricuspid, 
and iwualiy extend.s from the side of the sternum to the margin of 
the anterior wiill of the axilla, reaching from the thiixl to the sixth ^m 
rib in the vertical direction. Two of the cns])s or outlying ]iroce!sfle8 ^M 
nin towttitls the axilla (one above, the other below), and the third 
extends towiinls the edge of the sternum, often renchitig or over- 
lajijiing it. From it-s jiectoral surface minute lobules may jienetrale 
the deu[> fascia and even become enibtilded in the fibres of the 
nmscle. Immediately below the centre of it" anterior surface, and 
usually between the fourth and fifth ribs, is the mamillit or nipple, 
ardund which is the artnhi of discoloured skin, the lint of which 
becomes darker in ]>regnancy. The nipple is jjierced by numerous 
small lactiferous ducts. Its skin is thin and delicate, and contains 
a <|uantity of unslri[>ed muscle which is jirolonged into the areola. 
The skin of the arer)la jiresents a nuuiljer of little prominences due 
t<.i the presence of miniature lacteal glands (glands of Montgomery) 
in the subcutiineons areolar tissue. 

The gland consist.-* of about twenty distinct lobes enshcathed by 
the segments of a Imijih CApsule of cellular tissue. Each lol>e is 
abundantly sujiplied with bkM)d vessels and bius a separate Utrliferout 
(litft, whicli convei-ges towards the nijiple, and beneath the areola 
Ijccotnes dilated into n lacteal tiinm or amjiitllii (Fig. I, 3). 

The artrrUt of the breast are derived from tlie thoracic and 
external mammary branches of llie axillary artery, from the inter- 
costal arteries, and from the internal mammary branch of the 
subclavian, which runs behind the costal cartilages about half rui 
inch from the lionler of the sternum. 

Cutaneous Nerves and Vessels. — In the superficial fascia on 
the front of tlie chest are tlie niilrrinr cutaitfoiis branches of the 
intercostal nerves and of the internal mammary artery. They 
apl>ear at n-gular inten'als in the intercostal spaces on each side of 
the sternum an they pierce the pectoral muscle, and are of small size. 

The terminations of the descending branches of the suprrJUuiJ 
cerrical plrj-ut may also be found beneath, or ]iiercing, the jilatyenia, 
and crossing the clavicle in the jjositions ini]died by their luimes, 
viz., iteriud, cUn-ieular, ond acromial. Some twigs reach on low as 
the fourth rib. 

[The ]>eitondis major is to be put on the stretch by dmwing the 
arm from the side ami supporting it at a cimvetiient heiglit, il.s tilires 
are then to be cleaned from below on the ri;;ht, and fmni above on 
the left side. The sli-ong axillary fascia is to l>e left untouched.] 

Feotoralis Major (Fig. 2, 2) consists of a Btemal and a 



THE AXILLA. 



11 



cUvicalnr )iorticiTi, separated Bt Uitir origins liy a cellular interval. 
The sternal |>ortioi i «m r< from nearly tlie whole li-iii,'th of one side 
of the manubriiini and body of the stenmrii, muI by deejt slips from 
the f«rtiln|i;i.* of all the tnie ribs excejit tiif si-venlh, ami from the 
intercostal fascia, and is connected behiw with the ajioneurosis of 
the external oblii|ue muscle. The clavicular portion (irijifji from 
the anterior oiirface of the inner or sternal half of the clavicle, and 
is 8«]>aratcd from the deltoid muscle by another cellular interval, 
containing tlie cephalic vein and tiie humeral branch of the acromio- 
llionicic artery. The muscle is iiunrled into the anterior or outer edge 
of the bicipital groove ofTBe humerus, by three sujierposed lamina;, 
the su[>erticial layer consisting of the clavicular fibref, the niiiidle 
layer of the iijij^r Ktemal fibres, and the deep layer of the lower 
utenial tibn-* ami those from the aponeurosis of the externa! olilifiue. 
The latt«'r is continuous Ijelow with the middle layer, and its fibres 
cross each other in such a manner tliat tiioae whidi are lowest at the 
origin are highest at the ])oint of insertion, and i'i« ifral. It is 
more tendinous than the superficial layer, and sends a prolongatiuii 
over the long head of the biceps to the cajisule of the shoulder-joint. 
The action of the pcctoralis major is to Hex, adduct, and rotate 
inwards the humerus, classing it over the chest, luul by its sttnial 
filires to draw for\vards and inwanls the whole sca]iular arch. If the 
lUiu were rai.ted above the chest the nuiscle would depress it, or if the 
Lind were fixed it would drag the trunk uinviiids, as in climbing. 
It* lower fibre-s may also act in extraordinary inspir.itinu when the 
«nii is fixeil, as is seen in the ewe of ;isthnnitic peivious. It is 
\ the external and internal anterior thoracic nerves. In very 
I'lped subject*, muscular slips an not \infrciiueutly fomul 
i_\ uij4 ttl the siile of the sternum and superfirial to the jiectoralis, with 
which they may have gome connection ; but they are ninrc Ireipiently 
omtinuous with the stemo-iuiuitoid or rectus abdominis. A sliji, of 
Mime surgicftl interest, is often found near the axillary bonier of the 
moscle connecting it with the biceps or the latissimus dorsi. 

The Axilla. 

[If the arm is well drawn from tlie side tlie boundaries of the 
uilla or armpit will be readily sci'n, and if the skin luis not been 
already removetl from the posterior boundary (latissimus dorsi), it 
fhouhl now be turned bacK. The strung deep fascia will be seen 
((retching from tlie jiccUimlis to tlie latis>inuis dorsi, forndug the 
liue of the conical space known as the axilla ; and the student sliould 
tgaiu notice that it is impossible to thrust tlie linger deeply into the 
*paix nci long as the fascia is stretdied by the exlen>ioii of the arm, 
liiil that when the anu is drawn to the side the tingev eiilttt* ttsA^Vj, 



12 



THE AXILLA. 



and C4in feel tlie axillarj' artery (if injucteil), aiid the head of til 
humerus. The latei-al cutaueous hranuiies of the intercoslal ve^stsb 
and nerves are to be found liehind the border of the |«;ot<jr 
major, by carefully dividing the fascia j)ainllel to the ribs.] 

Iiateral Cutaneous Nerves and Vessels. — The first inte 
costal nerve has no lateral branch, but six lateral branches from 
upper nerves (from siud to 7th) will l>e found appearing at the sidftl 
of the chest, between the dijjitalions of the serratuii niagnus, and i 

I , , . . . • 
•• ■■'V\t!.2. 



i..-^ '• ,'v I 



Fig. 2.— The axilla (drawn by J. T. Gray). 



1. 


r-ephalic vein. 


lii 


■2. 


r(*t*turalu major. 


115 


3. 


rultoid. 


17 


4. 


I'tM-tonilis minor. 


18 


0. 


Lniii; tboraiic- artery. 


19 


6. 


Obliquus extern ue. 


20 


7. 


.Vlur Ihonicic ttrtcry. 


21 


8. 


SiTralus ftiHfrniu. 


22 


9. 


Medina nerve. 


24 


10. 


IjifinsimuB diireu 


26 


n. 


.\xillury nrterj'. 




12. 


Poali-iior llion'icic nerve. 


28 


13. 
14. 


Coraco-brachuilii. 
Long liubicapulur ncrvo. 


m 



rinar nerve. 

Teres ninjiir. 

Internal cutaneous ner>e. 

Subscapularin. 

Nerve of Wrisberg. 

Siibjcnpular nrterj-. 

liicepB. 

Mitldle subiicapular nerve. 

Intercu&tO'humeral acrve. 

Basilic vein beromiui; axilla^ 

vein, held o»idc by hooLt. 
MuKulo-apiral nerve. 
Trieei-w. 



THE AXII-LA. 



13 



accompanied by corre8pon<1ing arterial twigs. Each lateral cuta- 
neous nerve, except that of th"- second, divided into anterior and 
posterior branches, which tuni forwanls to the jiectoral region, and 
backwards over the latiBpinius dorsi rcKjiectively. 

The lateral cutaneous branch of the secnnd ner\-e passes down the 
inner side <if the arm to join the lesser internal cutaneous ner\'e, or 
neri'e of Wrisliei^, and is hence cjUIwI the intercotto-lnnntral lurve. 
The corresponding branch from the thinl nerve usually accompanies 
uid joins thi^. These lost luiut be found at once and arc to be 
carefully pivserved (Fig. 2, 24). 

[All the fat is to be removed from the axilla, and the muscles 
cleaue«1 »<> far 11* tliey air e.\]><>Bed. Care nmst also be tiikun not to 
Injur*? the fnllnwing slrui-tnres whilst cleaning them : — the axillary 
vessels (narliciilaily the vein) imd the lar^e nervee, which rire to the 
■ iiit«r side of the sp<\cc ; the posterior tiioi-acic neivc, whiili i iiiis 
verticidly upon the seriatux mngniis, neiir the postcrioi- wall nf the 
uilln. givin;,' ntf a branch lo eacli ilif,'itiitinii oltlie nin>cle ; the sub- 
•capuUr vr*4el» at the outer Imiiler of the suliscapiilariH ; the lon^' 
tborucic artery, uejir the lower bonier of the jiectoralis minor ; and 
the three xiilwcapular nerves which cross the space, jwssing from 
above ilownwanls ami outwards. One or two of the numerous 
lymphatic glandfi should also be preserved.] 

The Axilla (Figs. 2 and ;i) is 11 conical space between the chest 
and upper arm, and lias the following boumlanVs : — In^Jiont, the 
pectoralis major, the [icctorali.-< minor, ami the clavicle and sulKlnviiis ; 
feAiW .thc sulwcapularis, latissimus dorsi, and teres nuijor muscles, with 
the body of the scapuht ; to the imtauside, the serratus niagnus. >vitli 
the four upjHjr rilis and intercostal spaces ; and to the uuter^aitlf, the 
conicoid jirocess, the upfier iwirt of the humerus and the coruco-brfichia- 
lie and biceps muscles. The Imii'' of the cone has alroiidy lieen seen 
to be formeil by the axillarj- fascia, stretched between the anterior and 
fiosterioT bc(undaries,andthe apex is represented bvatriiinguhir interval 
between the clavicle, the ujiper border of the scapula, and the lir-st rib. 
Tbegrvat ve^ijela^d nerves, entering at the apex, lie aluiig the outer 
boundary orilie space, the artery being first on the outer side of tlio 
ner^'c ccirds, then belMX-en^ tKemT aiid the vein keeping to the ititier 
side of the arter\-, whilst most of the brunches of the arteiy take ti 
general direction towards the thorax. Towanls the inner side of 
the space, and imbedded in fat, are the glands, ten ^r twelve in 
numlier, which receive the lymphatics IVom (1 ) the front of the chest 
and the mamma, (S) the abdomen as low as the umbilicus, (3) 
bom the arm and (4) from part of the bacL The superficial 
glands lie along the edge of the pectoralis, and the vlec^wT OTi«:« 



14 



THE AXILLA. 



mostly in close proximity to the axillary vein, but others are found 
at the back of the axilla along the subscapulfir vessel*. They are , 

Fig. 3. 




IV m t» 



Fig. 3. — Horizontal aeetton of left axilU (after Biaune). 

13. Braehiiil nenvs. 
H. Ner%c of Bell. 



1. I/init toiidcm of bioep». 

2. I'octunilii* ninjor. 

3. ncnd of hiiineruB. 

4. AxilliiiT vein. 
6. Deltoid. 

6. First rib. 

7. Comro-bmchialis and bicrpa, 

8. .\xillnrv «rten'. 

9. Fut nf lixilln. ' 

10. Kxteniiil iiiteremtul. 
''~»'.i^li» minor, 
ic rencU. 



15. Ueltuid. 

16. Serratui magniu. 

17. Ten* minor. 

18. Subscapiilnriii. 

lU. Sii|iraiK-u|iulnr vcueU. 

20. Lung. 

Si. Scapula. 

39. Second rib. 

XS. Inlhi-iipiiiiilu6. 

34. lutenosUil. 



I 



THE AXILLA. 



15 



connected aboyfi jiith the deep ccn'ical glands, which are hence 
^SaWe to inffction in the later stages of uiucer of the brt-aat. 

Opportunity is to be taken, befure nny further dissection is made, 
to expose the lower part of the axillnry arterj" thorounhly, as that is 
the portion of the vessel to which a ligature is most easily applied. 
It should be noted that a portion of the subclavian arteiy is exposed 
in the dissection of the axilla. 

Surgery. — To tit the acxllarri iirlery. Tliis operation jk scMoni 
■<iuire<l, but can be jx-rfoimcd in two situations, nbuve or bilow 
be fiectoralis minor. Above tlic muscle the artery may be n-atbed 
a curveil or straij;ht incision below the clavicle, n-.-icbinK I'rnni 
ie Memo-clavicular joint to the comcuid process, ami ilividinj^ tlie 
Invicular fibref of the jMjctoralis major. The fascia ])r(donsed i'roni 
Tie costo-coracoid membrane to the stieatli of tbc vessels must then 

' incised, and the cephalic vein held iiside, when a brancli of the 

»mii)-thoracic artery will be seen, aud may be traced liown to (lie 
Killnry trunk, which has the vein to the inner aud the brachial 
»nlg t<> the outer side. 

Hrhir the jH-ctoralis minor the axillary artery may l>e reached by 
incision riai-aliel to the edge of the pectonilis uiajor, iitid about 
lidway in the a.xilla. The axillary vein liret comes into view, iiud 
drawing,' tliis iuwaids, the artery will lie fmiiid sunoiiinlcd by tiie 
ords of the bmchiid jdexus, which must be ilispbiccU in otiler to 
Itiose it. The aneurisui needle is to be passed from below (in 
I»i8 jiosilion), i.e., between the vein and artery. 

Both these oi)crations are ratliei' destructive of an important dis- 
ction, and shoulil not usually l>e attempted. 

When the axillary artery is lied the circulation in the limb will 
e|ieud mainly upon the anastomoses between the blanches of the 
1«ry aliove and r)elow the ligature, «>., of the sujierior and acromio- 
boracic with the subscnpular and circumflex arteries. The.se last 
will also bring Idoixl by their anastomoses wit!i the .wpra-scrtpular 
and pi*terior scajnilar arteries (roni the thyroid axis, a Iminch of the 
ibclnvian, and the thoracic branches of the subscapular als'j com- 
luuicate with the intercostal iirteries. 

[The clavicular portion of the pectorulis major is to be divided 

ically about its middle and n-flccteil, without injuring the 

ipliiilic vein, when branches of the aciomio-tboracic aitery and the 

ema] anterior thoracic nerve wilt be seen entering its under surface. 

■fer clearing away some Ic»ose cellular tissue, the coracoid process 

111 the insertion of the )iectoralis minor will be exposed, with the 

o-coracoid membrane above the latter.] 



The Costo-coracoid Membrane (Fig. 4, 2) is a strong fascia 

DMstiug of two lavTrs, which embrace the subclaviuK uuiscle. It 

I AttAched al>ove to the two lips of the subclaviuH gruovti on tVve 



I 



16 



THE AXILLA, 



id ejc^l 



nnder surface of the clavicle, internally to the first rib, and 
tenmlly to the corncoid jprocess. The two layers meet lielow, 
forming u distinct curved edge with the concavity downwimts. A 
thill ]irolon),'iition exttinls fnnii it to the ahenth of the n.xillnry 
vessels nnd to the fa-acio of the jiectorulis luinor, and is perforated by 
the cej5hiilic vein, the acroniio-thgracit-Xegsele, and the external 
anterior thorncic nerve. 

The SubclaTluB (Fig. 4, 5) is a small muscle which nritet by a 
tciulou from the first rib at the junction of boue niul oaitilagc, and 
is iusrrtrd into the groove on the under iiurfiite of the middle thinl 
of the clavicle. It is a dcpre«.«or of the clavitk' iind nhoulder ginlle, 
and is xijiylissUy^ 11 special branch of the fifth cerviculnerve given 
off in the neck. 

The ulualh of the axillary vessels is derived from the deep cervical 
fascia, and is 8lren}{lhene<l by a process of the costo-comcoid mem- 
bruie. It nmy be traced into the anu, forearm, and hand. 

[The costo-comcoiil membrane and shenth of the vessel.'? are to 
1>e carefully removed without injury to the sujierior and ncroiiiio- 
thoTJicic arteries, and the axillary artery and vein and bniehial 
ner\'ts in their upi>er part are to be cb-iined. This diswction will 
admit lijiht into tbe upper ]iart ol the nxilla, ami iillnw its boundariex 
and conientH to be bettef studied. The rriniiiiider of the pectondis 
major in then to be divided and rellected, to exjioiie tbe pectorulis 
minor willi tlie bm^ tlionicic art<.'ry at its lower bonier.] 

The Pectoralia Minor (Fij;. 4, 11) lies beneath the pectoralin 
major, and is inve»te<l on br.ith Kurfaces by a fimna which ii- 
attached above to the cost<}-iorftcoid nierubmne, and below to the 
axillarj" fiL^eia, dividing; the axilhiry space into two compartment.". 
It tir xKii from the anterior extremitieii of the bony imrtions of tbe 
thinl, fourth, and lifth riljs, Hometime.^ also from the iwcond, and 
from the iiilercoslal fiiscia, and is inserteil into the inner side imd 
upper Biirface of the coracoid process of the scapula, and commonly 
abo into an inter-muscular septum between it and the coraco- 
brachiidis. It crosses the axillary ve.'wels and nerves oblitjuely, 
and is wiid to diviile the artery into three stages. 

Aclinn. — The muscle draws the coracoid process downwards, 
forwnrtls, and inwunls, and with it the whole scapular arch, 
increitsilig the range of motion of the upper extremity in these 
directions. It is id.-.o an extraordinary muscle of inspiration if the 
comiiiid process be fixed. 

• mal anterior thoracic nerve, which per- 
*'■■■' ■'.•- :; ' i '"ml is major. 

ttunlis minor is to be divided two inches from its inwr 



J 



TUK AXILLAUY AUTEBV. 



17 



a, when the axiDai v vi-xxcN uiid nervi-i will be fully «'Xjm>»c<I and 
uiUKt lie cluiiinl. The ^iiiaII Iiitvi' uiiniyiii^' timii liiMwren thi- 
cry anil vein, anil pnii-rin^ llir |niii>iiilix mimir, i» tlin inumutl 
criur Ikorai'ii'.] 




W'^" '" ^ 



|Tbtt Axillary Artery (FiK*. J, 13, luitl 5, 4) ia tbu cuntiuumion 
' !;iviiiii, ami i-xtelulo fiiilu tllu lower l>oitler of the tinltib, 
nii'lilli' of llie iluviile, to the lower lonlcr of iLe ilwei 



Fis. 4.— Ih'i'ii litDMM-tion uf lli< «tilU ((rviu Itouaniy miil Be<iu). 



Tlr.T hi ti |ili \i> 



SefTktus umxDUt (u]i)nM iU;'ltii- 

ihtiri'ii ve««i'I« 



V 



li. AxilUry urtcn. 
^i^. Suhi>('.i|iuliir v< /tAt'Ii, 
U. IV.' 
1.^. Sll. 

Iti, M('<ii t,|>firttiiU)' M'en^i 

IM. Aiilliity vi'iii. 

^O. lUr|t[»M ntlJ riinii'»>t;rer!italU, 

'J2 Intcniiil t'utanrout nrrri'. 

V4. SutiM-iipuUirU. 

'.'i). 'J'rici'ii.. 

•it*. Trn'» inuji'f. 

SO. lailiwiuiii* Uiml. 

C 



18 



THE AXILLA. 



1 ~ 



tioD of the teresjiajor. In ite upper part it is placed deeply in tlie 
axilln, liut its lower portion is conipiiratively .=ui>erf5cial. The arteryj 
i8divi(le<LiJlIoJlirce_i>art,«, the firet, iibaix i tlu- second, Wii'mt; and^ 
the third, Wotc. tlie pcL-tonili* minor ; hut it alioiild he rcnu-mliered 
thnt the position of the muscle riliil'ta to Kiime extent with the move- 
nirnt-i of the scapnhiranli, and tliiit itn ilevelopiiii'nt vtirie.s consider- 
iibly in differeiil subjcrti. When tlie jH'ctonilis minor arises from the 
scfotid ril), it miiy couiiiletejy cover the u])per portion of the artery. 
The fnt 'log'-, of small extent, runs fr<im the lower bonier of the 
first rib to the uppier Ixpnler of j)ectonilis minor. It has in/rout 
the ])ect<iralis major niuwh-, the eostf>-eomcoid iiiemlirKne and the 
acroniio-thorat'ie arterj, and is enwwed liy the cephalic \ein and by 
the external anteri<ir thonit-ic m-TveiMiiiui, it has the lirsl intcrcosUiI 
space and second rib, with the first and secnnit digilations of the 
sen'atiis magniis and the posterior thoracic ni'iTC ; to its inner utile 
arc the uxillaiy vein, lynnihaltcs, and the internal anterior thoracic 
nerve, and to the onUr are the Ini'ge conls of the brachial plexus. 
This part of the artery generally j^ves off a sin>;le email branch, tin- 
SnjH'rior Thoracic. The acromii>lhoracic, which is usually de.scril>ed 
us a branch of this stage, nearly always arises iH-neath the ]>ectorali8 
minor and hence from the second stjige. ^M 

The lur'md tUuft (behind the fiectoralis minor) has in front tb*^^ 
pecttiralis major and the ])ectoralis minor ; lirhind'u a celhdar epace 
with the inner and posterior conls of the brachial plexus ; to its 
innrr tide are the vein and the lower part of the inner conl ; and on 
the iniUr »ide are the coracnid process, the cm-aco-ltracbialis, and 
the outer cord of tlie plexus. Tlie branches i)f this port «if the artery 
are the Acromio-Thoracic, the Long Thoracic and the Aloi^l 
Thorncic. ^ 

The third Mage (from the lower liopler nf the pectoralis minor to 
the lower l>order of the teres major) has in fmut the jiectorali-s major, 
the inner head of the median nene, the larye intenud cutaneous 
nerve, and the outer brachial vena comes crossing at a variable 
jioint to join the inner : lielow the lower tninler of the i)ectoTalis 
major the artery is sulxintancous ; iKliiud, it lies uj)on the lower 
part of the subscajiularii;, the tendon <>f the latiasirous dorsi, and a 
snnill portion of the teres major muscle, with the musculo-sjnral 
and the circumflex ncr\TBS ; to its iimctjMe is the axillary vein 
(fonneil by the junction "f the basilic vein with the veniB comites), 
with the inner head of the median nerve (for a short distance), the '" 
K '- and the lessi-r intt^mnl cutaneous (WrislK-i^-) nerves ; to the 

L * the coiiu'o-linichialis muscle, with the outer heuil of the , 

^^^^^^K ' cat, but lower down the entire nt-rve, and also the 



K^ 



THK XXILLABY AKTERY. 



IV 



aneoiiH avt-vv until il jiIithm tlu' oinico-lmalimlia. Tht- 
this ])urlioii fin- llip SuliMiiiiulur, Antoriur t 'imimllex, 
'PosUrior Circumllex, iill of wbich iLiiiully iiHai- ntar the lower 
'iMinler of the subsciipuLiris, 

Branches of the Axillary Artery ri>.>. ri). 

1. Tlio »iiyirrt'>r thnr<ii-ii (3 j" ii miull liraiK'll xuppl.vinj; tlu" »iile 
|»«r till- clu-nl iibiiul Ilii« fii-xt iiiiil wr-Miiil lib*, iiml uiiiv<t'jmti*iuK willi 

tiK' iiil< Hid! iiMriiiji.irv iitiil iiit>.'li'<»itiil arti:rii'-<. 

2. {tliurttcirnliiiiiuivriii : lliKTiirir. iLru) ( I ) U il 
lur^i :.. ; ' . Inmi lb<- urlcry bchiiul Uie ]icotomli» minor, 

I'Alid iiftw nyvcbiug the upjMT liordtr of tlie miiai-le, pii-nar* thu >it*ln- 

ontcnid mciiilininR and ilividr* Into four lirnnrhpn. Out (thuriu-tr) 

iiix forwnril to mijuily tin' iwrmtn* ma^^utls iliti'r<-<wtiil», ami iwcto- 

1 ' ' ' uroiiiiiil) jta*Hi.>t iiut>vanl» ti" the uiu-omion 

loiiKxiiiig with till- jtonlcriur circumllex lUiil 

xijiuUr ; ;; lUiiJ ;/iiiniT<i/) dowiiwurdii in tin- fp-<>ove ln-twit-n 

cloralin major ond didtoid liy the tide of ihf icphulii' vrin ; iind 

a femtli jclarinUiiT) u]>wunl>< lo tin- cliiviil« und nulxdaviin. 

3. T!r' tnri'i thoraru- (^) nuisuloii^ thi- lnwcr IxjnliT of th'; [nto- 
Ji-. I Ic' of till' <:hi«t, whrri- it .Hiniplim thi' munimu, 
id J -._ .me* cnllc-d thr rxtcriifti iimmiuart' orterj'. It 

xitnoH^ with tilt' intenml inainmnry, intun'ottol, acruiiiio' 
'lliorscic, uuJ KUbucApuLir iirtericK, A wimmli" rjrUrnnt mammary 
urti-ry uftcu ex'ml* in fenm!i'<*, parallel with but external to the long 
tliorocic, and tuuiHt^ iu supplying the breiixt. 

4. Tlip ii/<ir thoracic (3) are I wigs of >upj>ly In the luiltaiy jjliuida, 
Mom artniug directly from thn nxilliiry, but genenilly from itn 
itncheft. 

5. The- n'liMciijjuitir (ijj i» n loj^' brftiti'li which rUH" along the 
lower iHifliv .if tbc Huboeupulariti miH>~!e to (hi- -idi- of llir elieot 

pular nerve, to n, the 

i the itcupulumi'l i.;with 

intcrcoKlals, lonjj thomeie and «<:iipular iirtem-*. An ineh or 

from itii origin Ihif artery gi\es olf u lar^e bmncli, thn ilurtnlit 

VnUt (17), which winils round the lower bonier of the MiUtajm- 

miiiH'le, grtMii-jng the oxillary iNinb-r of the Arapula, and, 

er giving' a vtjutral branch, di»«piH'arn through n triangular 

'"Interval, laiuuded (a* wen fnrni ihe front) by ihe long head of the 

triteps, the tem« major, auil the nulKupularia. The lernunul 

branch of the xub-ciijiular ruun t^i the lUigle of the boue uud anosto- 

iijc<K-» witli til'- I'Mtiiiiiiition of ibe poNlerior M^upilliir. 

fl. 'l--y is a Muall liniiich wimling aroun<l the 

neck' ' ith the roraeo-brai'.hialix and bicepH, which 



20 



THE AXILLA. 



it supplies, givinj^ nl^ci ;in asranding bmnch iiji tin- bicipitnl groove 
to the shoiiliier-joint, iiml :i di's-ci-'nilin;; liranch to nniistotiiose with 
the snpi'rior nitiiftl folluteral linmili of tlie lirnchtiil. It terminates, 
by couuuunicattng with the posterior circnniflex. 




7. The potterivr rirntmjft.i (ii) in larger thaii the anterior, and 
winds behind the neck of the hunienis with the circumflex nerve < 



Fig. o. — Tlie nxillnry nrlfrv iiiiJ i1» bramhfs, the- pcctdral musclrt being 
removed (dniwri In ti. K. L. I'fsrsp). 



1. .Vcivmio-thdnidf nrtcry. 

2. Coito-coniwiid nifnibniiir wild cut 

■xillnry vfin. 

3. Superior thoniric tiiid nl:ir tlioriin* 

urteines. 

4. Ceiilulii' vein. 

6. lyonc tli'irni'ic urterj-. 
a. Aaillui y (irtery. 

7. I'eclunilis minor 0'ut)« 

s \(n-, nl,..i iitinieuuft MerAi". 

" • major !■ ut). 

|i' MTVe. 

'' ^'initii> magnuii. 

■•' cin-iiuillrx «rtcn . 



13. PoBterior thoruric uerve. 
It. I'lMtomliK initjor. 
I.>, SiiliM-iipuUr artery. 
I'i. I'lniir nerve. 

17. Dorsnlin wupulie ailery. 

18. Intemiil i'utuni-uu.i nerve. 

19. Cirt'iiniHex nerve (dniwn» dnwn). 
110. Xervo of Wri«lK'ri; joineil by m- 

tercofrlo-hunicnil nerve. 
21. External anterior thonuic nerve. 
The intenuU anterior thurncio 
diould b« (hewn eniergiug b<'- 
twern the uxillury artery au4 
vein. 




THK BKACHUL Pl.KXfS. 



21 



•npplv till' tlcltuUI, iiOMiiii);; ihtoUf'li a ((Unilrilulenil Bjinco liutltiilH 
(an mjeti iu front) by tin- ttTrn iiinjor, mibscnimliirix, lony hnul uf thai 
tr)ct']>a, ami thi^ tieuk of the hiimerun. It aUn ait|>iilii-« lirnnrhc* toj 
the (JioiiKler-jniiit, tlic greater tiiVM'i-cwity of tlio liiiincnw onil th« 
acromion. It anit«tuiurHiei< with tlie anterior circiituHox, the Ntipm- 
scA])ular fliid llie nuin'rior profuudit. 

The Axillary Vein (Ki}*. i, i8) Ucjjta. lilt inner- iWupf <h« 

It in foniKMl liy thf junction of thr busiliii visiii with thu 

^ta_comiif' "f the liriu'liittl iuUtv, umtiilly nwir tlir iijijior Ixmlfirof 

be ten-M ninjor, ami, liuvinj; n'ceivoil triliiitnrira .■ 'nff to 

be linmchvn iif the tixilliiry aittTy, and wimetiinfx il vrin 

SMwliuIely Ixjhiw tlie tlaviilf, it reuchi-a iLi* outer l>urUi-r uf the 

tit rill uiul In-couiei the nubt'Iaviun. Il in intimately reliitcil to the 

axillary lyiujihjitic*. 

BpB<^hinl N'erves IViti. 7). — Tin- Im ■! lonU uf tho brachial 

cxii <i fhini the luiti riiii f thr> -Ith (i-ommuni- 

iih, «tli, 7th, Hih oi,,.,., ,,...1 the greati-r \m' 'f 

|i i'TVi-A, which nuiki< their uppeutnnco in the |X'- 

■laiiyii- HI nil' niH'k (Part IV.}. The nerve* coiiltaiee unil ilivnii' 

■In tn a variable luanni-r («e« I'ostorior Triangle of the Neck), but 

rc<ull is thai Ihey enter the iixillu rtji three conU, lyin;; to the 

m.-r «iile of the (irst jiart ol thi^ axillar>' artery. Tho posterior ami 

.Is then |iitM- lirliinil the wroml utajje of the ve»<el, the 

lining ilH iiiurH' to rvach the inner xi'lo, while the outer 

main* ext^Tual ; ami the Beverul bnuiche" ileriveil from tlie«> 

,*U(l now to !«• exuiuined, uioix< or lew lurrtmnd the artery in 

ihinl }>i(rl. The plextla cuusL^Lk UL-ca>iunally of only two onl", 

^lieu it ei;t^ri the axilla ; in whieli ca»e a third cord t» furtuutl 

ilow the eUviele by the nnion of branrhes ilcrived from these two 

rdew 

(•ater (loril . . 
From 4th. 4th, 
Bth.nnil 7th eiti- 
vio.lI ner>c« 



al niexu* fulllied liv 

[6th, Oth, Till, Hih ri.r- 

mill l«t dornul 

with (-vtrntiiuni- 

hranch above 

th e<:rvlral , , 



1 Kxti'nml »nt»rii)r thunu-le. 
' Kxlemnl I'ulaueoiiH, 
I Outer Ueail of median. 



Inner eonl . . . 
Fioni Htli cervi- 
r,»l aihi l«t dor- 

Mlll tll'I V, K. 



I'lMtiTloi ford . . 
Knim itli, 6lh, 
7th, iind Mtk ccr- 
tii'iil nerves. 



Internal miterini- Ibnrmie. 

Inner livoil ot me<lMu. 

rin»r, 

lnt<'rn*l piitanmua 

Leaser Inteninl ciitunroiw. 

Tlin-e •iilweapular nervix 

(4tli, lith. 7th. and «th e). 

Mii><'ulo.apinil(('>Ili,7Ul,iuiU 

S(! \ nod Ath c 



fii 



ilinmlUth r.). 



•)9 



THE AXfLLA. 



Tho sevenil bruiiclu'g are to bv thoroughly identified, and theii^ 
relations to the vessels ai^certairied {viih Axillary Abterv) ; but 
the descrijitiou of thf ronjority of them is more conveniently taken 
at a Inter stugc of the ilisKectioii. 

The ExicnuxL anterior thamcicj'^rve (i i) is a small branch derived 
from the miter coni, guinj; to the under surface of the daviciilnr 
anil upper Bteninl [Kirtion nf the pectoralis major, which it sujiipliei'. 
It pierces the eosto-coracoid nienibnuie, and crosses the first stage of 
the axillary arterj-. 

The hitenial aiitirior llivnirir »irrre(io) Lf a small branch from 
the inner curd, which ]ijv=i<es between the axillary arteiy and ven 

Fig. 6. 




to supply tlic i.ieclorali» aunor, iUid after eoiiuniiiiicating with tl 
)ireceding m-rve, sends a twig through the muscle to supply the loj^i^ 
jiorl of the pectoridi-i niiijor. 



Fig. 6. — Uiagniii uf the l>rochiti1 plcxoi (C'lemeut Lucm). 



I'. Xene l« rhumboid. 

I't. Posterior thnittLic. 

bs. Supm-KHpulur. 

8c. Ni'ivc t" stibclnviiis. 
Ml*. Mi]M:uli.-(-utuiieuu^. 

M McJion. 
£at. Entcmiil nntrrior thonieic. 
UiB. Superior »ub>nipiiliir. 



I». Middle and inferior nilxcu- 
pular. 

C. Cirnimfiex. 
Ma. Muitcula-.'iiiml, 

V. I'lunr. 

Ic. Intfmnl cutaiieoiu. 
Lir, Leuer cutanraiu. 
IM. Inlrnul anterior thonoir. 



THK BRACHIAL PLKXl'S. 



ss 



■iitifif^ iFiy. 6, 19) ii< ft \tLrgf nerve fr<in> tlio posterior. 
' < iK-liiml t.)u< iixillurv aricry for a •liort ilifiUnci-, li-uving ' 
ibrii U) uMvimpHiiy till: poHierior cin-uiuMi-x iirtvn tlirouxU tin' 
ITiilril.itiral sjiuii' alreaiiy ilfucribeil, urij ^%iIlltin^ lomiil llie 
RU^ilv thf ili-lloiil, UTir> luiiiur, shmilder joint, and 
lu wliiiL it will lie sulis<;i|Ui*iitly tmcvd. 

Kij!. 7, 27, 28, 29) am flMivfid from tlio 

iiii ii::J. 1 ^, or middle, HuhHcapiiliir nrrvv i* Dfon at 

lower Viorilci of the »i«liHoii|iulaiis mii>i<'li< iKcoriijirtiiyiiiK tin' iiillf- 
[i|uiltir art*'!!', and Biidh in i1h< latitwiimiD dur»i. Tb*' Iwo •linrtur 
"ub*ea]iuliir mrvi'p will In; lii'ller di(wt.'iltd wliL-n thi- arm i» rviiiovifd ; 
upper eiiter» the •^uUsCiijiuluri.'t, the l(j»'rr the lulMcapulnrin and 
major muKclcr. 
The I'futrrior nr linni lUoimii- iimv (iMlrmnl rexiiinitory of Hellj 
't6' lie* ii|Hiii the -crnitiii. ioaxini», ^ivin;{ oti' u twi^j til enj'h 
■■•iti. It in a fiipra-eliivii'itliir liraindi o| the braehial p|exiiii,J 
"i frutii the fifth ulid Hivtli livrvex, with an uccayiunal hntnc 
Irum the »fvt<nlh, uiid deM-fiidif heltiiid the hmchial cunU ami 
axillary vesufU t'l il" dixtriliulioii. 

The Berratus Magnus (Fig. 7, J2; covert thenidcuf the cheBl. 
..,..■.... 1.. . .1.1 .1,..:. 1. .._ fr„i„ the outer surfiicen of the eight upper 
! il fiiM'iii, tj)e Hrxt di^itiition iH-inj; attui^hed 
10 III! Ill I ajM -riuiiu iiiin (jdiiiinx "" 'I'" latter the nei-oud di)(ila- 
lioii) iiiid til u tilirouH areh hridyiuj; the fn>l ifitercostal Jt|uii;e. The 
llUtrx hnvi' H ;.'i-iii!rid dii-ectiini l>ii<.'k\vanlH to a «peria1 area iiiioii th>i 
tuner nurtiic nf the Mcapulu hurilerinj; the verteluid iiiarj^iti, where 
bey are iiiMrl/jl, the lir<l two iii}jiliilioiin uiiitiii;^ to form a thicker 
arliou whuli in utlui'lied lo the upper aii^^le, while the liwl four or 

Ive, tile lower thn f whicli inleidi^itate with the external oblinue 

kiiw.ld of tlieiilHlimien, form ur-till lar^'er liiiinlli'. > oiii^iinndin^ to the 
uler i«irtion of the uikb iwljoininf; the ii. !ig dcapula. 

Artiun. — Thtj niii»ole iu< a whole draw >.i[v»tlaand 

itlj it the wliol« of the i«himliler yiriUe, the eentro of tho move- 

Bcnt being at the Hienio-clavicular joint. The lower digital ion* 

ting ttlonc draw forwanl the lower annlc of the in-apula and xo 

OtAti^ the |j;lenoid cavity ujiward.i and aid in thu elevation of the 

m, thiK motion oecurrin)^ iit the luromio-clavicular urticulutiun. 

piv muwie has no inthieme upon the re-ipiratnry niovuuients. It 

I obvioiiH from the diiidion of it* nvrnition* in relation to the axi's 

the iKinex to which ihi-y are sieverally alt.uhcil, that were tins 

apula llxed the coiilraction of thu niuxclo, except jn'rliajM in the 

fcaf the but di};italion, would leud to depieoa the riba. It in uut, 

er, a muscle of expiration, becuufe this act ie iudepeudent of 



■1 


in 




^^^^^^H 


B 




^^^^^^1 


■1 


THE AXILLA. 


1 


■ 2-^ 




k 


1 


7. 


3 


1 


J 




i 


^^^^^^^ 


B !^ 


Be' 'I' -iia^H^K* 




^^^^^^^^H 


V os^^ \^PW 


^^^futem1|| ^I^^BM^^k 


^^^^^^B 


^^^1 


1 J^^m 




.^ 


^^^^^^^^H 


■ *:^^^KBf^^^ 


uflBHB^BB^B^^B^^^^^^K- 


■ 


^^^H 


■ ^'j^^ma 


f^^f^H^K^V 


- 1 


^^p 




I^^^HH^B 


-;■. 1 


^^^^^^ 


^' ' tf^'^rirfH^r ~ " '"^^Krr^MlUm 


siBk^H^^^^^Jf^^Br^^l 


^ 


^V 


" ^nHP^S^J^P^fofl^^^l 


^B9^^^^^^^ ^^^^B^^l 




^^^^H 


/s^^^EKgJsHP^l^^nS^^H 


^^^^^^P^^^KKS--^ ^^^^^^^3^^ 


Cf 




J ''^^Hu^VS^^^^Vsvfi^^^^^^^l 








^ v^^nEtrV^ ^!«^^r /"^jSa^^^^^^^^l 






^H 














^H 


T • 


^^^^EB^^^^^^^^r" *' 




1 


4 


J^^" 


1 


^ 


Fi|f- 7.— The iiiTviw uf thr- iiNillii 


(fniin llii"!iibfeld «inJ LcTpillj) 


1 


1. 


S^al<*nti<h Tn(Mliu.«. 


17. .vrii*nijl*)-rntnm'oun iieiTe. 


■ 


•i. 


Scak'iuH antii-UK. 


18. Orivin of pertiinilii' minor. 


■ 


■J. 


CorJ f.)riiii'cl by 5th and 6th iit- 


19. Meiliiin nerve. 


■ 




vionl in'nr>». 


20. .\■er^■e nf \Vri«lMT(r. 


■ 


4. 


7th coniral nvnf. 


21. Ci.niCo-briiili|jili«. 


■ 


Sapnuiriiiiuliir ncnre. 


22. Interi n«to-huniera] nerve. 


■ 


(S. 


Sub'i'ivuin Hiierv (i*ut). 


2.3. rinar iierviv. 


^ 


•_ 


Inmrlinn of Bubclavius. 


2J. SubiM-ap.iluri*. 




s! 


I iir<l foniicd by 8tli oiTvicjl uiiiJ 


I'l. Itnicliiul iirlery. 






l«t dnr»nl niTvw. 


20. Lnttrul cutiiniHiiii braneh of 3rd 


'.). 


PtH'tor.-tH* mnjor (n*flculed). 


inten-oRtul nerve. 




^ 10. 


Internal nntcrior tboraiii- nerve. 


27. Xlitldb- nubseajiuUr nerve. 




H 


KxIcmnI anterior thoraeie nerve. 


28. Short lutuKiipulnr nerve. 




H 


Ori^n of t'ubclavius. 


29. I.oii}( ^uln-uuiilar nerve. 




H 


I'lM'lornlin miliar (refleeted). 


30. I'l-etiiraliii ni'ujor (eut;. 




H I*- 


Intei-niil cutaneoun ner^e. 


31. Uanilji' vein. 




H )«. 


.^itilUirj- arti-ry (cut). 


32. Serrutu» maK^iUf. 




L 


I'Mtorior tbomcie nerve. 


33. LatisxiniiiK ilnrti. 


^ 




PBONT OK THE UPPER ARM. 



25 



tatiun of thv Huipulu. lu fssvntiul uscd are in iviuLiiiK, puxliiii^ 
' Dtrikini] in arorwuTddin-cttou, niirl in niisiri); the arm. Wilh tlif 
lioniboiJ*, it kci'pd the vcrtcliml bnnlrr i>f the- lump applied to the 
ar^t wall. 

Iiffffii/iuM lyf tlif lAitiaiu iuM Harju. ttnilXcta.Mniiv, — The iipjirr 
irt of the lutixMiiiux wiiitlN nvfr the lower aii^'lc of ihv K-apula, 
rliirii it i-tivrlM|ii-ii in n xorl of fold, unil umU in u broad, thin 
ttiilon, which piL«<-< in fitml of thii tvrcH niujor to bi* |'jijrffii(i iiit" 
be luittom of till- I'icipitnl groove of the hiiniKnis. An in the oium! 

llu- lower ixjilJon nl tlip pfi'tornli.-i iiiiyor, thr fihri-a of the mintcli- 
twilled »o that tho»c which were hi|;!h('«it ut their origin iirv 

••••*l ul thi-'ir inwrlion, and ricr rrrnA \ it in Ihi* tiarrowL>«t of ihi" 
trru It'iidons inwititl into tJii- bicipital {groove. 

'flw UmMfjuojui. {iiuau iK-hind Ihu tendon of the latlv>imu> dorxj, 
111 i« interUd luti' the iiimo' or pootirrior vAgf; of the bicipitul 
ivr, oppofite the jipctninljii tnnjor, unil i» w]>Brale<l by a bursa 
imi the iuM-itiiin of the IntiMiniiiM. 

OpportiMiii.v nhonld Im' liikeii, when the i-UvicI*- lit i]tviiie<l by the 

wtttir of the neck, to tmcy the nxillnry iierviit to tboir ori(;in«, 
pd tu «tudy llie brachinl plv.\u», the deicriptiou of which lit given 
ith Uie " I'osli-rior TriHOgle." 



Thk Front nr ibk I'prKB Arm. 

incision i* <o be nnule down Ihft front of tin- iimi to n point 

nrlu'ii lH'Iow'lh<' bend of llie ellMiw, wheic it i> to be joined by 

Ktv*K cut hulf round tlie foi«iirni, imd the .-ikin '\» to I* re- 

. ou rnch xiile Uir u coiiiile of inches, (o allow of the ilmection 

»)]>erllcinl nervei anil veiux. The intercoHlo-hnnieiid nerve 

tIic inner and juwlerior part of the arni in tin- «)iper half. 

cinii of xhv. ami ure veiy vaiiiible, and th- bent way of di*- 

thrni, theretore, will be to follow- l>oth luiHilic and cephnlir 

down to the elbow, and to Imre out their tributarie?. The 

ktrrtml rutnneouH nerve will be IVmnd near the luiniliu vein, and 

kl to it the nerve of \Vri«lM'rK, the Intureoiito-hunieral, and 

Kti'mnl eiiiani'oUH of the niUH'-nhviijiiral. With the meiliitn 

lie. vein is the extenml cntjineous niTVP, nlwivc and nulxide 

\t\» are two external entaneoug brnncheti of the tnuMMilo-xjiiral ; and 

»r the deltoid may Im- seen »onie twi;,'ii (jf the i iiriniillex nerve. 

Iir dtM-p luH'tu ia not to lie removed.] 

Tlie Internal Cutaneous Nerve (Fig. «, 8) l» to Ih! followed 

It (rmi. iln Inn, I io?,l ,,l ill. nlexiuilothe fore-arm. It liw at fitvl 

fr, . of the axillary artery, and then, 

,,. ....J, .(.-,... .,,.,.,.1 Uie middle of the ann, at or neor 



26 



FRONT OF THE UPPER AHM. 



the point at which tlie basilic vein entero, it runs in front of the 
inner cnnclyle und, !<ubiiividing, sends branches both over and 
under the median bftsitic vein to the inner side of the fure-ann. A 
posterior branch winds above the inner condyle to the back of the 
fore-arm. 

The Ijesser Internal Cu- 
Fig. 8. taneouB Tferve (Ner\e of Wris- 

bcrj;) (Fig. 8, 2), niter joining 
with the intcrcosto-hunieral nerve, 
pierces the fiuciii ut a variable 
point, and supplies the lower third 
of ihe inner side nf the upper anii 
behind the internal cutaneous 
nerve. It is not ahvaj-s Jiresent. 

The Internal Cutaneous 
Branch of the MuBculo-spiral 
Nerve 1 Fi^. >*, 6) a]>i>eiirs on the 
inner side uf the n|i])ei- arm, below 
tlie teres niiijor, and is distribul4-tl 
to the iiiiit-r iiud Imck putt of theanii. 
The Median Vein (Fi)?. 8, 
14), arising in a plexus al)ove tile 
wrist, runs iij> the centre nf tlie 
forc-arni, and alter receiviug a deeji 
vein (prolunda) divides just below 
the elbow inl^] two branches, the 




4 



Fig. 8.— Superilrinl dissrction of the ' 
urm (froniHirK'hfi'li) nnil Lrveillf). 

I. Arrominl nerves frum sii]ierfiriiiL 

wrvicul pIcxuN. 
'i. Nerve nf >N lislMTft. 

3. 3. CirruniHi'X nerve. 

4. Intcriosto-liuiueral nerve. 

5. Ce|ihulic vein. 
G. Intcrniil riititticnua branch of I 

ciil"-»iiind iiiTvc. 
7, 7- Ksti'inul 1 iitiintuuii brancbM 

uiUHi'ulii-tvpinil nen'p. 
K. Intcninl ciilMneotis ner^'e. 

II. Kxicnml cutaneous nene. 

10. Ilnfilic vein. 

11. Ilndinl vein. 

12. Dinar vrini. 
U. Median vein dividing into median*' 

basilic and niedian-cr|ihalic rein*, 
uuil juiniMl by tlie ilveii median. 



THE MEDIAN CEPJIALIC VEIN. 



27 



m*di ii< wtiii'h jiU'W obliijucly inwunla 

iSar i -t ill fiii'tiung the !i:i.^i!i'' iiml 

capholii: vi'iiiM. Tli«? ^iv'/ii»(/« vL'iii j>ii'ixc» tlie ileeji fn- 
bend of th« eDniw to Joiu thf lucdiiui ueur il« iioint ul > u, 

utid furmi> u cumniniiicntioii l>t*twn-ii the iviicr ctmtilft of tlip arti'liwi 
of the fonr-anii mid the supcrlicinl vpinii, the direction of the curnslll 
of blu<id mninn in different MibjcctJ. 

The Anterior luiJ Posterior Ulnar Veins (Kig. ft, 12), 
aruin}: from the verui .'diIvjUoIIi) >« }i. 4Hj iin<l intcmnl ilorsal plexus 
end on the inner side of the fun'-arin in a MJnjjlv trtnik, which unitt-s 
with the lueiliun Ita-silic to fi<rm tlie luutilic vein. 

The Boallio Vein (Fif;. h, 10) runs up tlie inner side nf the 
untf lo iiljoiit it> ni'iddU', whrrti it pierees the deep fuftcjn and is con- 
tinued up intn the iixilliirv vein, rvceivinir, at a nvriiil'lc |>oint, Ihe 
vcnie lomite* of the liriuhiul iirU-iy. Tu the inner *idc of the 
bMllir mn, niid ahout an iln'h iilxive the condyle, i;t a lyniplmtic 
glkod of sninll HJ/e, which dnutm the luuer part of thu bond nnd 
foiv-arni. ltd efferent c<>rd>, with the root of Ihu fur^-arm anil hmid 
lyniphjilic«<, end in the nxilhiry glaudit. 

The Radial Vein ( Fi^;. H, 1 1 ), arining fnnu the nblial ilonul 
]>lexus, tiAcendfs on the oiitiiT fide to join the niediiui a-phalic and 
fonu the Cephalic Vein 15), which piu>i<c» up the outer »iil« 
of the lii'-c)*, mid tlim between the jiei'torali* major and the deltoid ; 
it ha.« dlreaily Ueii triicid to it> teniiinatimi in the axillary or »rtl»- 
clavian vein iIo«e to the miler iMHiler •■!' the tlp"! rib. 

The Median Boailia Vein hua important ixdutlono. >ilnr« it lien 
Mi|K'rfii-iiil to the bruchiul artery, and cnkvies over or under the 
internal cutnneoU!> nerve. It i.i the vessel usually aeleitud for 
VeneKeelion on lucouiit of it<' iii/.e, Some protection in ulfuided to 
the artery In-neath by the intei'[HBilion of ihi' bicipital or nemi-luiiur 
(iiwin, n tendinnim i-xjiannion troiii the bieepa (Fi){. S), 2>), 

The Median Cephalic Vein i* mtualiy of xnmller sixe and 
cnMww the tendon of the biceps, dole to the outer »ide of which, mid 
Wnttath the vein, the External Cutaneous Nerve (Fi^. s, 9) 
piercer the fattcia uml divide into iti iiuleiior iunl jio-iterior brHnche>i 
tu the fon--ann. Above and lo the outer «ido of the external culu- 
nrau* nerve an- two f.rlrrnal i-\itiinrtiiit hniiifht* of the minfulotpirul 
nerve (7), the uppi-r and ^nutllcr one running alony the cephalic 
vein to tlie iip]ier and oiiti-r jmrt of the front of the fore-arm : tJie 
lowi 1 to llie back of tho foiv-ariu ; and the culam-ou-i 

bnui' ' rtrc«/ii_/fc.r nrrre (_j) «niei>;e fruni below thu ileltoiJ 

to ROch tlieir di«lribuliou over the ehouliler and arnu 

The Deep Fascia of the arm ia tiullicicutly iteeu in following 



I 



28 



FRONT OF THE UPPER AHM. 



.■ fascial 



the Buperficial ve-tfc'lf ami nervcp. It is coiitiiiiioiis with llie fascial 
of the axilla and fon-arui, nnd is ntUiched to the supra-coudylnr 
ridges of (tie liiimerus, foriiiiti;; the external and internal intermus- 
cular si'ptn, wbic-h give nttacliiiient to niui-ciilnr tiLres. The iulrmol 
iiilerniii«n(lnr cc/idim is tlie stronger, au<I in nfttn jiierced )>y the^B 
lllniir nerve and the inferior profunda and anastuniotif nrteritsJH 

The rj-tiniiil is jiiereeil br the 
niusciihj-t^jiir.il nerve and suj)erior 
profumin tirtei'V. ^t 

[The miisdes of the front of 
the iirni are nnw U> l«e elejined 
lufjelher with the vessels iiiid 
nerves, hid the IWcia on the 
opjier part uf ihe nnistles of ihe 
liite-arni need not hr ilihturhed, 
(iiid care must he taken not to . 
ilisplace the vexselM and nerve*^ 
Ironi their naltind jKisitiona.] 

The Biceps (Kij;. i), 9, 12) is] 
the superfieial nuHch' of thej 
upper arm and arisea by twt»J 
hcftdsi, which jjenerally unite in] 

Fig. 9.— Muielm of the front of 
the uppiT linn (from Bonamjr_ 
Miul Ueiiu). 

1. Corneo-claviculiir ligtinumt. 
•J. Claviilf. 

ii. Arronii^vcliiviculur li^iiiciit. 
•I. Coniroid pr<>ieM. 
o. fdnuo-ncriMiiiil li^inent. 
0. IVftornhft iniiinr. 
7. Heuil of fiuni)TU« enrliisnl in <'iip*1 
Rule of wtiouUler-jomt. 
Conu'(t-hnirliiidi«. 
l.nni; lu'ttd uflih'ep*. 
10, Sulmriipulari«. 
J I- I'ertoniUrt mHJor (till). 
1:'. Short lieuil of liiopp*. 
Kclniid (lUt). 
l,iiti?isinm<i donii iiiitl Irr 
coinluned. 

15. Tendon of bi>'«|M. 

16. Lonjt head of triro|W. 

17. Siipinutor lonfTUM. 

18. Inner hiiid of tricrpn. 
20. ilr.K'liiahii antirui'. 
32. Dii'ipit il fiiM'in. 
24. I'roQutor radii tere*. 






THE BICEPS. 



21) 



li- uppiT lliirii of the anil, but occasionally rvmuin ilistinut tii-nrly to 

heir iiisprlimi. Tin- /o«;/ or nutrr head, lint to l«; fully tmctHl at 

CHjiit, iirUtK M'ithiii till' ca|MiiIo nf Ihi: »limiliUr-joint from thu top 

' the gWiiuiJ cavity, hihI liinti tlio kI'^»<>><I liKaninnt. Thv tvinlon 

(Verxing thv joiul niiJ eticlu^eil in k titlw of HyTtnvinl membruDe, 

Item the Ijicipitiil groove nf tlie liuiiivrtiK, and u iw*».'n to cmKruf fnim 

^p CMpxiiUr linmiirtit and lie upon ihe tcudon of th*" lutt»«iniu-> iIomI, 

nJ lK'lwi-«-n tlii^ insertions of tlm ii«.tonilw major mul i it- 

ta*clcf>. Tlic rh'irt or I'niirr hcml ariua from tin- tip of i I 

Fi». 10. 




L(- KLiijiulu, ill comnioti with, liiit to tbe onti-r nulc of, thu 

^ biulii, and tin- two lifiiiU iiuile to form a liirjtc ll»hv 

Th<! lil>rf» ciinvfr;;f to a liniiul tendon, from wUich i« given 
IT, iinnii^lintrly iibovc thv flliow-joiul, lui i-xpansinn, thu liinpilnl 
unnilunar /turiii, rt<<;4!iviii); «u]K-Tfiu'ial fll»i\'s from liotL b<<ad«, 



lU. ^bia^^mnuitiii •M'tiuii of «1iouli)«r thiouch liiripital in'oore (W. A..), 



h. Urtt'.icl. 

[;;. AtT'*fiiiuu. 

f». S.i' 



joint. 



.-lit. 



0. 


S>' 


10. 


1,, 


11. 

12. 


tcmltiii 
!Iuinrni< 



ii iiurtioii of bii'v|M 



30 



FRONT OF THE UPPER ARM. 






and ^ ivtrrtod into th« fascia on tin; upper and inner imrl of 
fore-nmi (22}. This would have to lie divided in order to follow' 
the tendon of the liiceps (15), which jiasncs deeply to lie iw^ertfd 
into the pnstcrior honler of the liiei|>ital tuhercle of the rudius, a J 
bursa heiiig phu'.ed lietwi-eii the tetidoa and tlie smooth anterior sur-fl 
face of the tuhercle. It will be seen in a later dissection. The 
tendon liecoiues llntteiied near its inserlion, and is twi^itt'd *o that 
its OMfer edge lx?comes mittrioi: Tiie chief action of the hiceps is to 
supinate the fore-arm, and to tlex it upon the n]H)er arm, the radius 
then reprexenting a lever of the thinl oiiler. The long heH<l slightly 
abducts and Hexes, the short head adilucts and Hexes the humcruK. 

The Coraco-brachialis (Fig. !>, 8) nri/us from the tip of the 
coraeoid process, in coinnioii with, but to the inner Bide of, the 
short head of the biceps, from the tendinous upjier ]«irt of which it 
also takes origin, and some "f its innenuost t'lhres are usually 
derivetl from an intennuscular se]ituni tontiectiiiu it with the 
jK-ctoralis nnnor. It is i>iereed by the external cutaneous uer\-e, 
and is iniurltt! into the inner side of tlie shaft nf the humerus about 
its midiUe, opposite the insertion of the delloid, and into a pro- 
cess of deeji fascia continuous below with the internal intemiusculnr 
septum, ami extending ujiwanls us far as the head of the humema.^ 
It is a Hexor and aihhictor of the humerus. V 

The Brachialis anticus iFig. 1-2, 11 ) nr/sx fitmi the front of the 
shaft of the humerus in iU lower half ; and the fibres have also an ^ 
extensive atlaclinient to the front of the internal inlennuseular B 
septum, and a smaller one to the upper jmrt of the external inters ™ 
muscular wptuni ; tlic origin is bifid above, the two sliii.s embracing 
the insertion of the deltoid. It is im^rlril into n rough triangular 
imprexsion on the u]iper extremity of the ulim, immeiliately lielow 
the coronoid process. It covers the front rif the cajisub- of the 
el bow -joint, luid is intimately conneited with the luiterior ligamenL 
A considerable portion of the muscle apjiears superlicially on the 
<iuter side of the anu between the biceps ami triceps, but it is 
covered in front by the biceps, nnd is overlappecl Imlow by the 
aupinator longus, extensor cnr|ii radialis longior, and jironntor radii 
teres. It is the direct flexor of the fore-nnn uimn the upper ami. 

The birep, coraco-brachialis, imil briichialis anticus are mippUal 
by the niu6culo<ufaneous nerve ; and the brachialis anticus has an 
additional snpply fnim the musculo-spinJ nerve, whici gets in 
front of it Kdow and close to its outer border, under cover of the 
supinator longua. 

The Brachial Artery (Fig, 12, 14) is the direct continuation of 
ill«ry, and extends from the lower bfirder of the teres major 



i 



THE BRACHIAL ARTERY. 



31 



to its point uf bifurciitioii into ra<liid and ulnai- arteries, about 
half an inch below tin' Uend of tlie idbiiw. Tht artery is puper- 
ticial, or at least crossed by no luuscle, in tho whole of its courst-, 
but may l« ovtTlappe<l by a wtdl develi>jK.'d bii-tps ; and it trradiiiiUy 
tarns from the inner side of the iinii to the middle uf the bend uf 
the elbow. 

lu front it haj" the gkiu and fifcia, with the iiitemal cutaneous 
nerve until thi." pierces the fjuscia, and about the middle of the arm 
it i« generally crotwed by the itieilijin nerve (but the nerve may ]>ass 
li^neslh the vessel) ; at the lieiid of the elbow it is also cri.)sse<l by 
the bicipital fascia and the median basilic vein. Behind it has first 
the inusculo-spinil nerve and su]ierii>r profunda vessel.", wiiich sepa- 
rate it from tlie Ion;; head of the triceps ; it then rests u[)on a .small 
portion of the internal hea<l of the triceps ; next, on the insertion 
of the cfinico-brachialiR ; and afterwards upon the brachiaiia anticus 
fi» the reel of its course. To the oiiirr side is the median nerve, 
with the conico-brachialis muscle for a short distance above, and 
aflerwnids the biceps nniscle, which is the guide to the vessel in 
applying a ligature ; both these muscles overlap the artery in a 
muscular arm. To the iinirr side is the ulnar nerve, in close coutnct 
above, but soon leaving it to ]kiss backwards to the holhiw behind 
the internal condyle ; and afterwards, from a varying point, the 
niMlian nen-e, which continues in close relation to the vessel for the 
rest of it» course. The basilic vein lies to the inner side of the 
artery thmuglioul its course, but is in elost?r cont-act in the upper 
|iarl than the lower, Lf., after piercing the deep fascia. ^'en!B 
ci>mite» surrounil the arterj" in its whole length. 

Surgery. — Tn lir Ike hrmhiiil osicnj. An incision, three inches 
long, is to bt made close to and exposing the inner edge of the 
liirt'-pn in the mid<lle thiitl of the arm. A little dissection parallel 
to the muscle will e.xjKise the niciliaii nerve, and the artery will he 
found in close relation to it, and generally to its outer side in this 
position, but tlii« will vary in dillereiit bodies. The needle is to lie 
]iMeed/r»ni the neive, cue being tjikeii of the veiise comites. 

When the brachial artery is tied, the circulation in the limb will 
1« maintained by the anasloiiioses between the bnuii:lieH of the 
srtery above and Udow the ligaliire, viz., of the superior profunda, 
and possibly of the inferior profunihi above, with the uuustomotic 
anil with the recurrent bnuuhes of the ludial, ulnar, and inter- 
oweouH arteries below. 



The Branches of the brachial artery (Fig. 1 1 ) are — 

1, MxucuhiT, arising at various points to supply the coraco- 



1 




^F 


^^^^^^^ 


1 


3^H 








UPPER 






:i2 FKONT OF THE 




brachialLs, Inct-ii!', and liracliialis 


aulicus 


tijUi'i'k'.''. Some arc of^| 




Iniyt- eize. 




^H 




2. Medullary or Niitriaif, wliicli 


enter!} tlie fumiiien on the inner'^^ 








side of tlu" hunieru* 




Fig. 11. 




about till' iiiiilille of tliu 




/^^. Y 




l)oiii', and lias u geiieral 






direction lowtirdt iLe^J 




\\\^J^-' 




^H 






3. Siijieruir radial^^^ 




I "j/J^r 




ruUaIrm! of Henle. A.^| 




\z^r^~^ 




Miinll and inconstant ^H 


Fig. 11.— Din^'i-um of th«^H 




V 


LTr- . 




iiniutniiio»nt of (ha ^H 
brucluid artery, ^^| 


.1 p*^^. 


Sy > 




1 


■. 


f\ 


/'" 


1. .Vntrrior •inumflcx. ^H 

2. .WrKiiiiii-tlinnicir. ^H 

4. Liaij; thoruiic ^H 

5. Superior ruilial coHn- ^H 




I li Wl \ 


ff 


terul (exeesnivcly ^H 




1/ \ 


n 


liirgc). ^H 




/ 


Ij. SubK'ujiulnr. ^H 




/ 


7. .Sujioiicr jtrofunda. ^H 




\ ■■' a I 


y 


H. Dur^ulinMiiptiliu. ^H 




„ _i ■■ A ■ 1-' 




y. Kxtemiil pcwterior iir- ^H 
tieulur uraneliof fiu- ^^| 




— 1 It 








i li 






perior itnifuuda. ^H 




I <n 






10. Ponlerior •uijiuUr. ^H 






' ft 






11, Kxteriinl itiilerior Hr- ^H 






11 






tii'iihir bruiK'h of «u ^H 






t 






perior piiifumla. ^^ 


< 


11 — 1 


It 






1'.'. liilirior profundii. 


•% 




It 






la. l'ip«teri<ir iiiterotsrou* . 




1 






riTurrnit, ^H 




i ' 1 






14. Aitiistoniolicn mugnn. ^H 




/; 1 


/ 




hi. Itsilml reriiin-iit. ^H 




/H ' 




16, Transvcrae branch of ^H 
anastoniolieuniitj^iia. ^H 




m- \ '" 




17. Posterior iiit«ru«icou* ^H 




IS '^ - 


■It \\ 




recurrent. ^H 




/ 


a W '* 




IH. Anutotiiiwixifiinterior ^H 




^' 


'If 1 ) 




utiinrrei'cirieutwith 




- / - r ^- 




iiuufiloniutk', 
19. I'oKteriur interoaM'OUt ^^ 




IS \V ISk. f] 




from eoniiiioii inU-r- ^H 




u^md - -° 




us^eouK of tilniir ^H 
20. .VniutoiiiosU of pocte< ^H 




mi " 




riur ulniir reeurrcut ^H 
with atiastoniotie. ^^ 
22. .Vhterior uliur reenr- 

ivnt. ^1 


1 


» 




24, Posterior ultuu- recur- ^H 






BKAXCHKS OF THE BRACHIAL ARTERY. 33 

liranch which runs transversely outwards a little a1x>ve the middle 
of the ami, to the point of insertion of the deltoid. It supplies the 
muscle and auiutontoses with tlie posterior L-irciimflex. 

4. The iSii/jrri/if jini/iinda (Inferior radial collateral of Henle), 
which comes off from the inner side of the arterj', juRt below the 
teres major, and immediately joining; the iiiusculo-apiral nerve, 

oui]>anies it between the outer and inner heads of the tricejifi 
d. under cover of the lon>{ head, round the humerus, to etui by a 
email iinterior trrininnl branch between the bnichialjs anticus and 
rapinator lonjiTiis in front of the elbow, where it anastomoses with 
the radiiil recurrent artery. It gives off a jiodcrior umlulUini branch 
to the humeruH, ami miiiuulur branches, principally to the triceps ; 
also tlie pontmor terminal or tUtceiidintj artinilar, larger than the 
anterior terminal artery, ninning behind the external intermuscidar 
wptum to tlie anconeus and back of the elbow, to anastomose with 
the posterior interosseotis recurrent and anastomotic. 

5. The Jiifrriar proftinilii, which arises at a variable distance 
below the jireceding or in common with it, and piusses with the- 
ulnar nerve behind the internal interinusciiliir septum. It runs 
with the nerve to the groove between the inner condyle and the 
olecranon, and there joins the posterior branch of the anastomotic 
mnd the i>oslcrior ulnar recurrent arten". 

6. The Aiiu.Jiimolir, which arises an inch and a half above the 
elbow and runs directly inwai-ds, sending* an anterior descendin;; 
branch downwards alonj; the edge of the pronator radii teres to join 
the anterior ulnar recurrent ; and then jnercing the internal iuter- 
inascalar sejitum gives oH' a /loWfr/or flf-jtcevdiini branch behind the 
internal condyle to anastomose witli tiie inferior profuiula and 
poBlerioT ulnar recurrent arteries, and a large tri(iij»rrr»e branch To 
join the deiscending articular brunch of the superior profunda and 
the posterior interosseous recurrent behind the outer condyle. 

IrrtyiilarUin o/ tlie Brachinl Artrnj. — The point of bifurcnlion 
occasionally much higher tlian the 1»cnd of the eliiovv, the 
ormul branch being usually the radial, souietiiuea the ulnar, 
and more rarely the interosseous. Sometimes a id-i nherrfini! leaves 
the brachial or axillarj* and, passing in fnmt of the median ner%-e, 
joins either the radial or the ulnar, uriiially the former : or the 
'- '-'.il may consist of two tninks, which unite before the final 
. ision into radial and ulnar. If any of these arrangements Ije 
prvMrnt, two large ve.ssels will be met with side by side in some 
i«jt of the arm. The lirachial artery is sometimes found passing 
with the median nerve lhii>ugh a fibrous canal beneath a process of 
boue above the inner condyle, the tupraamd^lar procat, to tetwit tXa 
B. D 




34 



MEKVES OF THE ARM. 



noniml position at the elbow. It is occAsionally covered by 
flei<liy slip connected with thf coraco-hmchinlis, Viiceps, brachialis 
nnticus, or pronator ten-s ; and otlicr less common iietiiliarities are 
-oniftinies met with. The two jirofunda nrterien not iincummnuljr 
ari.se together, and oc^-asionnlly there is an axis coninioii to all 
princijial branches of the bmcliial. 

Venee Comitea are in dose relation witti the brachial artei^J 
and wcoive twigs <-orre'<]tonding to iU branches : they unite wit 
tile li««ilic to form the axilliirv vein. 



Nervks of the Arm. 

The Hedian Nerve (Fig. 12, 6) is derived from the outer i 
inner cord.'* of the bnirhiid lilexiis by two roots, which cuibmce tb 
axillary artery in tlie thinl part of it* couwe. Tlic nerve aflerwar 
lies to the outer -nide of the axillary nitery, and continnes in 
same relation to the bracliiul urtejy for about half its length ; the 
crossing over (or occiuionally under) tliitt vessel, lie* to its inne 
fide, and continnes in the same relation to tlie iMjnil of the elbow. 
It gives off no branch iu the upper arm until it reaches the level 
of the inlcmal condyle, where a small (wig ia detaehed for the 
supply of the jironator radii tere>. It oteaHionally communicates 
with the niusculo-cutmeoiis nerve. 

The MuBCulo-cutaneouB TTervo (Fig. 12, i) arises from the 
outer cord i>r tlie brachial jilexus in common with the outer head of 
the median, and lie.H to the outer side of the median nen'e ouj the 
axillary vessels for a hhort distance. It then pierces the coraco- 
bmchialiH ublii|HeIy (hence calle<l ji. itrrfuntnn I 'iixsrrii), and liuving 
given a branch to that muscle, it lie.« between the bicejis and the 
brachialis anticus, both of which it (inpjdies ; sending also a minute 
twig with the nutrient arterj' to the humerus. It finally becomes 
cutaneous at the outer side of the tendon of the biceps ju«t above 
the bend of the elbow, where it ha.s U-en already seen to lie beneath 
the median-cephalic vein. 

The Ulnar Nerve (Fig. 12, 8) arises from the inner coixl of the 
braihial j.lexus, and lies close to the inner side of the axillurv 
vessels, and afterwards in a similar relation with the ujiper jiart of 
the brachial artery. It leaves that vessel about the middle of the 
arm, ami then jMUwes through the internal intermuscular septum 
accompanied bj the inferior profunda artery to the interval between 
the intcnial condyle and the olecranon proces.«. The ulnar nerve 
gives no branch in the upper arm, but suiiplies a fihiment to the 
elbow joint. 




TUE MUSCCLO-SPIRAL NERVK. 



S5 



nv Kusoulo-Bpiral Werve (Fii,'. Is!, 13) U derivefl frimi the 
erior Colli uf till' liiuihiaj IiIcxuh, iinJ lien ut firnt lifhind the 
'ary artery, and ujmiu the nibitcaiitiluriii miwclt: witli llic circiim- 
: nurve. It thvu ivnU upon iLe Lutmaimus doi>i and t«rv« nuyor, 
, Hfter giviii;; off iin inlfrntit cutantout branch to the inuer side of 
arm, which UHUolly ariac 



Sututuun with the hmiich to 
iiiner hfjui of the irice.p, 
Ijuc.kwanlii arouiul thu 
pcruii in t.hi< muM-ulu-Hpiml 
pre, lying ajfiinBt the inner 
of the triceps and aftM^ 
» liutwcfn it uiid the 1 niter 
of that muscle, h^ri- giv- 
off Iwii tjtenuil cviniifoiu 
cbf«. Hr»uila'»t'i till" triceps, 
Dneiu auil outer portion of 
' bt«chlalii> anticuM will )m 
ill a mibsrquent diiucctioii. 
ItH lower ]iortion u vi«ible Ikv 
liii: supinator lon^iix ttnd 
hiatis iiiiticu)!, to liulh of 
icb and to lln- cxli'iiMor ciirjii 
lia loDgior brunchcM iituy 



Flir. 12. 



I'li. — Pwp diaoctiaD of lh« (rtmt 
[if tlir u|)|»'r uiit (fhini Hirwiifald 
lin.l J...v.-illr). 



< llUlUl'OUk tli:rv(i. 



..( jc. ■ ti.riili* major. 

I UUI'VU. 



LfUUiuoiu ncrro. 
kticu*. 
Mmrf. 
■I ucrvo. 
Idlorjr. 
Dg-iu. 

1 rutiiDt«>u« braui li 
■•piTBl ntd-*o. 
1 UTH. 




36 



BEND OF THE ELBOW. 



be traced ; and it ends by division into radittl and potleri&r %»Uer- 
OMwiu nerves in front of tlie cxtemnl coiulyle. 



The Beijd of the Elbow. 

[The lioundnries of thi- space in front of the elbow are now 
be expoHwl liy renioviiij} th« Jascin from tin; niiisclen of the fore- 
arm to the extent t<> wliich the Bkin has been already reHt-cted, the 
tendons of the biceps and brachialis are to Vie thormi^'hly cleaned, 
and tin* fibre* of the 8ii|>inator brevis in the floor of thi- sjiaoe oa 
fully di8s<M-ted. The terniiujitinu of the brachial artery and 
lueilian nerve are to be cleaned in the middle line ; and at the out 

side ail- to be dehned the bilur- 



Fig. 13. 




cation of the niut^cnlo-spiral nervj 
and an anastomosis Ijetween 
superior profunda and the radi 
recurrent arteries, ami at the 
inner side an anastomosis be- 
tween the anterior bmnch of the 
anastomotic and the anterior 
tdnar recurrent, with some Iw 
from the inferior profumla.] 



rio£ I 



The Triangle in ftront of 
the Elbow (Fig. 1 3) is bounde<l 
iihure by an imaginarj' Une drawTri 
across the anu above the condyles, 
and helow the apex is formed by 
the meeting of the ]irona 
teres and supinator longua, ti| 
inches bcluw the joint. 
edernal boundary is the 8U] 
nator longus, the intcnml 
pronator teres ; whilst the fld 
is formed by the lower part 
the brachialis anticus, and 
ternul to this may be seen the 
oblique fibres of the sujjinator brevis when the supinator long 
is drawn aside. The relations of the superlicial veins and ne 



Fig. 13,— ITic bead of the elbow (from University College Museum}. 

1. Biceps. 5. Anaitomo»i« of superior profuq 

2. Median noi'vc. with rudiul recurrent. 
8. Muscuio-apiml uene. 6. DnuhinUs anticus. 

4. BrucUial lutei y imd veins 7. Supinnlor longus (turned bjck]( 

8. I'lMuator term. 




PART8 ABOUT THB SCAPtTLA. 



37 



hare Ittsea ulitady cxMnin««l (p. iS), ami the ermtmu of the iipacc 
nciw ii<M:n to be (1) tho nuulinn ii«rve, (S) th« 1iin«hUl artciy, 
B<1 (3) the t«ndiin of tLf biwi>8, which lie in lh«t onler fn'm 
ithln outwanls. The luMliuii nerve (2) runs Hliii'>»t vertically 
Brmi^h the it]iace, uul <ltiui]>peani Wtweeii Ilie heiuU nf the pro- 
nator tercB : the briuhiul urten,- (4) uxually bifurcnlen into nulinl 
unil ulnar upon the uiMtrtiun uf the bmchiutia iinliciifi, the nulial 
resting' uguinH the U-nilnu of the 1)ico|M mid tin- mipinator btvviii, 
und the ulnnr lying upon \\w braohintis till it di>uip|>i-ant l>encnth 
Ihe promiliir teri'ii. The twiHting of tho bicep tendon haa nlrcndy 
iK-^-n referttsl to. 

By aliKbtly dixplocing thei«upiniitor lougug outwanU, the niUBculo- 
•piml uer^-e will be M-en Ivin); between it and the bnichiolbi lUiticUH, 
ontl dividing into nutiAl and ponterior intero9»i'ou« nerves ; but thin 
iicr\'e ill nut, strictly nfienking, in tho triangle. Tho rulini nor^'e 
may l« lnic«d for a xboit diHUnoe upon the xupinntor brcvi«, whiUt 
"r interoMieouH Ui the inner side of the radial can l>e seen 
-• libtvs of the muscle. 



^ 



in 



It IB «up;io»t;<l that by the time the diMcetion of thit l>end of the 
bow U linixheil the eubjrct will be turned, in which rni<n the 
identof tlie ann *bonld dissect the flrxt two layers of the muscles 
of the Wk (wf I)|KisK(rrt<iN i>|f TltE lUcK), phKU'eiliiig afterwards 
with the following diiytcciionH. If nvceewiry, however, the dinneetion 
of the front of the fore-iirm tuny be ]iroveeile<l with l\niL Since in 
some dioaeetitig-roomn the diwiector of the ariu Ium no {xtrt in the 
buck, the following directions are given for the removal of the 
i,b:— 

[The two auperflcial Uyorwof the miiDi'les of the bock romprixe the 
tmpcxiu", liiti*>.imu8 dursi, rhomboidei, and levatfir nnguli wapuln'. 
These huvinn been divided, the oupmscapular arteiT and nervf and 
cimo-liyuid niuscle are to lie tnice<l to the upper XtorSvT of the •enpiila, 
and the [xiotcrior «aipular arlerv followc<l l>«neuth the rhomboid*. 
1 ' cle lian U'eu already divided in the dicBection of the neck, 

I ■ can now be drawn away from the ribx and will be seen to 

aiiarhi^.l sidely by the nerratux inagnuK, lietwern which and the 
;}>« is a (inttiitity of loose hirge-nieshol uretdar ti.-wue which allows 
e bone to glide xmoolhly uixin the thorax. The nerralua niagnns 
viug iM-eu divided, and the clavicle cut at its middle if still 
tire, the aiilhiry vevseU and nerves are to be severed after being 
ltd together, and tho entire limb removed from the trunk.] 

Parts about thk Scapui-a. 
[The limb having been placed on the table, it is ndvlaable to 




!Mr««nl iiwntiowrfi 
I iadi 6wi il» i 

TW h i n f tiu * of Ike icapeaa* csieHb iliig the ^Pfet boricr of 
tW (ftee ei Um! «ea|iak, tke iiocT header o( tkr ■iiiiiiMi, and 
th* ovler tliinl of tk* yoiterior bovder of tke daviefe. TV ono- 
\iycM amei fna the ofper ■ungia of tke ttmfmU dcae to tb« 
■n<cli «a4 froB Ibe Uimeit *%»■'—« TV levator mgoli 
wy lw ja iMeiteil ialo Um* pan of tV nrtehai bocder «f Ute 
«ai|i«k vkidi ii above tbe baaal tata^ at tV not of tbe ■pnc^ 
IW ikcaiUiMeiia mbor into tbe pan opyarile the baal triu^ 
asd iV rbomlmidea* major into tbe ttat, of tba bolder, bjr mtaa* of 
a lemlbtotM anil to which tbe mnacular SkmM ate ittirhfd Tbe 
•MTat«w magnna ia uiaeited into a ipadal aica nnuaiag alo^g tbe 
T«ntnd tiufac« of the acapiila clute to tbe vertefacal bolder for i 
whole Icnijtli, but the iilires are much thicker at the vppex 
luwiT auxleii thau in the middle. The ^nall inteition of the | 
minor i* iiit&cbed to the inner holder and upper razlaoe of 
curiu.'uid j>r(ict*«, thr tiji of which process gires odgin to the cor 
Lracbiali» niul the nhort hea<l of tbe bicepet 

[A idimll block u now to be iilnced beneath tlie lower border of tl| 
(K-ajiiiIa «o aa to put the deltoid on the Btretch, and the remaiader I 
it* filrrcK Hit" tln-ii to Ix- ileaiifd, notice being takea of one or ( 
amnll bmnrln'* of the circumflex uerve which turn ruuud ila paste 
UiriliT. nnd of a few d(j*cen(linj4 acromial twi^ from the suptrfici 
bniui'bcit of the cervical plexuii (Fig. 8, i) which supply the rkiu 
the choulder.] 




Tbe Deltoid Muscle (Fig. I'l, 6) xrw-ji bom tbe iuiteri( 
IxinliT of the outer bulf of the clavicle and the ailjacent portion 
the •iipcrior iturface an far an tbe curved deltoid ridge, and from 
UiK ti|i and outer edge of tbe acromion, and tbe lower lip of tl 
■liinp of the Hcapula. Its strong coarse fibres converge to 
iutrrlfd into n rough V-«haped surface ou tbe outer side of thi 
liiiiiii'ruH ii1>ove the middle of the vhaft, and are embraced by the 
bind origin of tbe brncliialis anticuH, and closely connected with the 
iiiwrtion uf ibi- |K-ttonilin major. Tbe muscle i» coun>cly faitciculated 
and uitiToecled by teudiuoux bunds, four of which above are attached 
to tul«!rclf-» on tbe outer border of tbe acromion iirocess, and three 
bcbiw to vertical riilgeti on the deltoid impresssion of llie humerus. 
Fig. 1 4 will iiiilic4»te the tyjiical orrangenient of the librvs, Imt many 
vnniitioiin iii'i' met with. Tbe action of the deltoid as a whole is to 
ralai! outward* the arm to the level of the abuulder, i.e., to abdui 



M 




[uc^ 



TUE DELTOID. 



39 



liumcnw; bttt the anterior filing will aautt in flexion anii 
c-mal rotatiuti, nuJ llic iHwU-riur iu uxtt<ii«iciu ainl t;xt>'nia! 
lioii of iLe •briuldrr joint. It i» tuyiditil by the cLrciuiilii-\ 
erve. 

_ [The deltoid IN to W divided near its ori>>in and turned down, ihu 
I'liuiflex veHMilK iiiiii lu-rve bi-iu^ iirvKiTVvil. In doin^' thi« a lar^u 




Tnt; I»'twci-n the dolloiil iiml tlie ».hould<T-joint ohould l>e 
ptici'd. The ivntuiUH ol th<; tiitix-ziuii niUH-lit iin- to Ihi cut rlo»i- to 
kit *pino of the (tcipiilii, nud (he lliin fuoviu covi-riii^ tin- muikIhs 
'>uva uud livl'iw it rvmovi'd, the liiiiut.'ril!t bvin;; rutiitud iuwanls to 
Ut tlieir Uhif" oil tho i>llvl< h.] 

The 8ub-aoromial Bursa lini-a tlic intervul btrtwoen thu u|ijht 
of the tihouhlor-joint iind thit under surfiic*> of tliv deltoid, 
eruuiion {irocvix, nmt roniro-acroininl ligament. It tliiw forms iin 
KtenHivc «ac, thi; euhir^fnicnt of wliicli may W confuiiiidiMl with 
I of titc joint. I'byeiologicAlIy it rvprvoentJ* a nynoviiii lininif 



Fi$. li.— I'liin of tlip dcltoiil (aHcr Ciinuinnham). 
I. Ut"M<rtrniTiii<iii» intrrMH-ltfiiuHi-it- A. Iu>wcr truilitinun int«nimttion» rp* 

iuImii ri'iviiiB; thrt* of the unprr •r|f. 

CI uiruttoflliemiui'leauillnMlitiU 

8|<<,i : : I • liitu Itiimtfniii, 

l^iv I ; :< .'Iiirtiti. 



42 



PARTS ABOUT THE SCAPULA. 



tin; 



infia-epinatu? and teres minor muscles are external roUiturt M 
adJiictors of the humerus. 

The Teres Major Muscle (Fig. 15, 7) arinni from the Iowa 
portion of the triaiij;ular tere3 area, ot the inferior angle of th 
i^capula, and from the intermuscular aepto between it uml the ter 
minor and infra-s]jiiiatug muscles. Its close reUtiou to the latissimu 
dorsi Las lieen already noticed, but its iimertiun into the inner lip 1 
the bicipital groove and the bursa lietweeu it and the tendon of 
latissimus should be again clearly seen. It is supplied by the I07 
i<ul>scapular nerve, and is au atlductor and internal roUUor of tha 
humerus. 

The Posterior Circumflex Artery (Kij,-. 15, 4) with its veins, 
and the Circumflex Iferve (I'ig. K'>, 3), appeiU' throu;j;h the 
quiidrilatend H)ince (see pp. 21 and 4U). The nen-e is distributa 
to the deep surface of the deltoid muscle, and to the teres mine 
mu.scle (the branch presenting the above mi'iitimied enlargement 
anil supplies aI.so the shoulder-joint, and the skin over the lowe 
part of the deltoid and back of the ami. Tlie posterior circumllex 
arteiT not unfre<iuently arises from, or in common with, tlie sujieriot^— 
pitifunda, in which case it is below instead of above the teres maJoii^| 
It sui>plies the same parts as the nerve. ^* 

The Dorsalia Scapulee Artery (dorsal branch of subscapuUr) 
(Fig. 15, 11), does not pass through the triangular s|>ace as seea^H 
from behind, but winds beneath the teres minor in u groove on th«^| 
axillary Iwrder of the scapula, to supply the infnuspiual foasii and . 
anastomose with the other .scapuhiT arteries. It gives off a ventral 
infrn-iiniiuhxr biuuch, which will be aftiirwanls traced beneath the 
subscajiularis, and a superlicial branch, which runs between tlie 
teres major ami minor and down to the angle of the scapula, to 
anastomose with the subscapular and posterior scapular arteries. 

[The Buprn-spinatus and iufra-spinatus are to be divided near their 
insertions, and tlie muscular til)if s cleared out of the supra-spinal 
fossa in order to see the supi-a-«capular artery and nerve and the 
origin of the omo-hyoid muscle.] ^H 

Tlie Supra-scapular or Transversalis humeri Artery 

(from the thyroid axis) jiasses over the transverse ligament of the 
scajmla, and is distributed to tbe supraspinal fosKa, and also to pa^^B 
of the iufraspinal fossa by a branch which winds around the extenu|^| 
bonier of the spine, and anastomoses with the dursalia scapida) and 
jKisterior s^-4ipular arteries. Before crossing the ligament, it semis a 
mipriiHurrominl branch through the attaclunent of the trapezius, and 
a tubucapular twig to the venter of the scapula. 



A 



THB SUBSCAPULAR NERVES. 



43 



Thf Bupra-aoapular Nerve (Fik- 15, i) (from the anterior 
uches or the Htli ami 0th cervical iirrvfn) giveii li bnuiuli tu thv 
buiildcr-joitit un<l |>aMie.s throuj^li thu miprii-iiciiputur notch uixl 
cnuotti the ligament, to Ik; i1i«tribute<l to the. xuiirii- und inrni- 
pinutiix mii'a.'Io. 

Thf Omo-hyold llusole urtmt fri)in aliout half an inch of the 
ajwrior IxmkT of the Bcaimlii, iinmeiliiilviy lK'hin<l tho «upra- 
upular notch, iinil from the lniii»vui->ie or puBlerior li^'amiMit over 
It* wlatiuna and iuaertlm nn^ oeeii in the diiwuctiuu of thu 

ck. 

[The limb is to \m: turned over ntid the humenw rutattwl outwnnl* 
|i> put the libreM of the Mibitrapulnria on thi- stretch ; they should 
"ben Iw cleaiuil, cjire l«einj; taken of the i>uh>u.'(ii>tilar norvv* entering; 
'liij axiiliu V ve»celH and nerve« Htiniild be tieil to the 
Ml 118 to tiring them u« n(>arly "» niiiy be into their 



•J... p. 



,.] 



The Subaoapolaria Musole (Fifi. !(, lo) i» iiovrrcd by u thin 

iMO, and him liieji iiln-mly hi rn li» form jwrt of tho {xMtcrior wall 

■ tlic axilla. It (iMJiM fmiii the wlioleof tho venter ^ciipnlic, e.xr.-pt 

ftc part to which the vmitus magnvta It attaidied and thu imitiDn 

eareot the neck of the Ijone, and hax Beveral IvndiuoiiM Hepta lie- 

vvcR iln libn-!!, which are attached to the nd^e^ on the «urffti:« of 

bone, and bear some rejiemblance to ihiwe of tlie deltoid. It i» 

<rfed into the Icswr tul)ej»«ity of the hiinicni.t and the bone lielow 

for an inch, and intt) tJie cajwular ligament of the shoiiMer-joinl, 

large bnmu inU-rvfiiinji; U'twcen the niuxcle nmt the neck of the 

npitlo, which a]ino«t alwayt coiuiuiinicateit witli the luivity of the 

ftint over tho up[ier bonier of the tendon. The iiuWapnlnri;^ i» lUi 

nai TiiatoT and adductor of the htuuuruii, und in sitjijilied by the 

bolt mbsoiiudar uerve«. 

An important action of the suptu- and infni.«pinati, teren minor, 

ipularin miim^leti i» tlii-ir combination to keep the hroil of 

Mis in ilK proper relation to the «lenoic| cavity, anil thiu 

^evunt dinlocatiou. In the iMMt-iuortrai rclaxnl condition of the 

the heiul of the hnmeriin can lie drawn away from the glenoid 

tvity to till- lull eitent of the loom; cut>Kidiir li^'uuierit. 

The Subscapular Nerves (Fij;. 7) are branclicBuf the p<.n>terior 
Uml of the bracliiiil plexu*., and are thn.-e in number. The long or 
llddle «nl>^capuIaT uer\'e hott Im-cu alri-ady <ecn in the axilla, and 
III ittill lie traced to the latissimua dorsi ; the short «nlMeapular 
itrveM (upj)er and lower) are now to Im followvtl, the upper to the 
iliecapularii) muscle, the lower to the aubocapulariii and terex migor. 




-tffifU in%. B, 7) ■;[ I'M! aboat tbe laiddfe af 
< min4 IW MM, and raw « lw » «i i l » waA fmrnaiAt alotig 
tfM •fpcr put of the Ii9f»«m: tlw Immt 
I *t1m09 «iac (Flip. 16, 6), aiilMaa doae sb««v dte esUriMl 
tf1*t "t^ *'U U aOenranU tnoed dowa tbe back of the fore- 
bit IW vriii; sad dM tkinl or iuUrmal euUntoHt bnuieh 
I lit* Umi» Mar Um tendun of the I<tm major aad rapplies an 
I «• d»* imttr Me vt the arm behind that of the intercosto- 
(n», », 6). 
I fMM IIm inUmat cutaiuoiu and JeMcr tnltmal eitta', 
i wUI la trnvd ijtt thft inner »ide nf the limb, anil filam 
Ih* (fr" fve run (liiwnwur<l>i over the Iwck of the arm, 

• liiwrr |>art of tlic deltoid (Fig. 16). 

[Wlrt-n IIm Hi'inu d««p foacia of the anu has been divided, the 
niiiH:lu uliduld 1)0 cleuned, and a large bur 
l.ir jiudteriMi' aurluce of the ulnn and the 
fill - . 



nea(^H 




THK TR1CKP8 



Tlu- TrioepB Musele (Kig. 10) ba» nf course throe beads — Uie 

Bng or tiiiijcllr, ihv f.xtcnml, and thf intrmnl. The lomj (j O bfjul 

urj Itviu u nomnwlmt Uiuiigtilur n>U(;h «urfttc-c on tlic oxillor}' 

itxler of Utr M'n]iula iiuuK>iliuU.-ly beluw the glnioicl cAvity. It 

be*-!! olrt'Uily jAltly ex- 
tuimrd liotb frcui tbo ftiml luul 
nm MiiiiJ in n-liilion Willi 
trtiiili ►jiotes (pji. 19, •lOi, BJiil 
bns» an* now Keva to In- 
tt«il by aiujtiirr tuiinvwhiU 
Dgitlur intiTvnl iwtn tin- 
of thi' iip|ior tbiii] of tlie 
», until il juius the ex- 
briul at the Junction (if 
u])]icr with tbf uiiddlo ibinl 
' the lioftft. Tbc iiutrr hi-JuX i^} 
from iuiinodintcJy bcbiw 
iiuM-Kiiiu of the ten>8 minor, 
nd from llie outvr oidv uf the 
•ttrrior ii8}><.-cl uf tbu l>une, u>' 
down aa ibi- luuKuloHijurul 
fo; a! ' V from llie 

unl liar «4']ituin 

1iU-)i !'<:• I >. 1, ■ , (',\. .11 it luid 

dlllo;.! h l,,Mil- n tiui- 

Liiua urch ovi-r lb« muwnln- 
k1 nervB. The tnncr head 
tij) ariMt from the wboltf of 



ri^. 16.— OiMTctinn of b««k of upnvr 
■rm (frani Ilirm-lifrtil itDil l<eveflu). 
' 1. tnfn-«i>iii«li». 

X lU'llniJ. 

T«rt» minor. 

(lutirr bouU uf Kti'cp*. 

Circunifli'x nnrc. 

>Uli"ttinl ••ii'iiufoiii bniiiili of 



mil iicrvi". 



7. 1 

10. I 

11. v.. :.. 

li .\i....... .. 

13. IniK I li. .<>l ..l 

16, Ulnw nmrii. 



ilU Inoglur. 




36 



BEND OF THE ELBOW. 



be traced ; and it ends by division iutu radial and potterior 
OMMiu nerves in front of tbe iixtemiil condyle. 

This Bend or the Elbow, 



I 



[The lioundnrii'9 of tbu space in front of the elbow an- now 
be exposed by reiiioTiiig the fftscia from the musclen of the fore- 
arm to the (-.xti'iit U> which tbt' skin bus been iilreiidy reflected, the 
tendons of the biceps and brachiali!- are to In' thonmnbly ileaned^H 
and the librc" of the 8U]>iiiator brevis in the lliMir of the simee ''ora^H 
fully dissected. The terinitintioii of the bniL-bial artery and thp^^ 
niedian nerve are to be cleaned in the middle line ; and at the outer 

fide are to be delined tlie bitiu- 



Fig. 13. 




Ciition of the iiiusculo-spiral nerve 
and an anaslomosiit between the 
superior profunda and the radial 
reciu'fent arteries, and at the 
iiuier tide oti nna-toiuosis be- 
tween the. anterior branch of the 
aujistomiitic and the anterior 
idiiur recurrent, with xome twigs 
from the inferior profunda.] 



The Triangle in front ol 
the Elbow (Fig. 1 3) is bounded 
iiliutr by an imaginary line drawn 
across the arm above the condyles, 
and Moir the opes is funned by 
the meeting of the pronator 
teres and supinator longiia, two 
inches below the joint. The 
tTterna! boundary is the supi- 
nator longus, the inlenml the 
pronator teres ; whilst the floor 
is formed by the lower part 
the brnciitalis anticus, and eX' 
teinrd to this may Ije seen the' 
oblique fibres of tlie supinator brevia when the sujiinator longus 
is drawn aside. The rehitionB of the superiiciol veins and nerves 



M 



or 

M 

he" 



Fig. 13. — llic bend of the elbow (from X'nivcrwly College Muneum). 

1. Dirpps. 0. Ana»toBiMi» of supcriur jiro(\iud 

2. Mfduiii Don'e. with radiiil rerurrcnt. 
8. Muw-ul»-«]urul oervo. 6. Bmcbialis onticus. 
4. Btadiiul iirter> uad reins, 7. Supinntor longua (turned bjck). 

8. Pronolor lensi. 




PARTS ABOUT THE SCAPULA. 



37 



have been already exominetl (p. S6), and the mrUrtitii of the space 
are now seen to be (1) the median nerve, (2) the biachiul artery, 
and (3) the t«ndon of the biceps, wliich lie in that onler from 
within outwards. The median nerve (2) runs aInuiBt verlictdly 
through the sjmce, and di-mippcais l)etween the heads nf the pro- 
nator teres : the brachial artery (4) usually bifurcates into mdial 
and ulnar upon the insertion of the brnciiialis anticiis, the radial 
rertinj; against the temlou of the biceps mid tlte supinator brevis, 
and the ulnar lying upon the brachialis till it disiipiiears beneath 
the pronator teres. The twistiug of the biceps tendon has idready 
been referred to. 

By slightly dispkcing the supinator longus outwanls, the musculo 
«pi»l her\'e will be seen lyinj; between it and the brachialis anticus, 
and dividing into radial and posterior interosseous nerves ; but this 
Der\'e is not, strictly sjieaking, in the triniij"Ie. Tiie mdial nerve 
mar be traced for a short distance upon the supinator brevis, whilst 
the posterior interos-seous to the inner side of the radial can be seen 
entering the fibres of the muscle. 

It is aupjiosed that by the time the dissection of the bend of the 
elliow i* finished the subject will be turned, in ivliich cjise the 
ftudent of the arm should dissect the first two layers of the muscles 
of the Uick (tee Uisbection ov tub Back), proceeding afterwards 
ith the following dissections. If necessary, however, the dissection 
the front of the fore-ann may be proceedeil with tirst. Since in 
■onic dissecting-rofims the dissector of the arm has no part in the 
back, the following directions ore given for the removal of the 
limb : — 

[The two superficial layersof the muscles of the back ciimprise the 
trapezius, latissimus doi-ei, rhorabotdei, and levator nn^ili scapuhe. 
Tliese havinj; Wen divided, the supi-a-saipidar artery and nenre and 
omo-liyoiil muscle are to be trsiced to the u[)[ier border of the scapula, 
and the jiosterior scapular artery followed Itencnth the rhnmboids. 
If the clavicle has Wen already divided in the difsectiou of the neck, 
the scapula can now be di-awn away from the ribs and will be seen to 
be attached solely by the serratus miijjnus, lielwfen which and the 
ribs is a ({uantity of loose large-meshed areolar tissue which allows 
the bone to glide smoothly upon the thorax. The serratus nmgnus 
baling been divided, and tfie clavicle cut at its middle if still 
fntire, the axillary vessels and nerves are to be severed after Wing 
tied ti^ether, and the entire limb removed from the trunk.] 

Pabts about the Scapcla. 
[The limb having Wen placed on the table, it is advisable to 



38 PARTS ABOUT THE SCAPULA, 

identify ngain the several insertions of niusclea on the scapulfl, cuttiii] 
each muscle about an inch from its attachiuent] 



Tlie insertion of tin.- trajieziuH extends along the upper border 
the spine of the scajmla, the inner lionler of tho acromion, and 
tlie outer third of the posterior horder of the clavicle. The omo- 
hyoid arises from the ujnier margin of the scapula close to the 
notch Mid from the transverse ligament. The levator anguli 
scapula' is inserted into that part of the vertebral border of the 
scaimta which is above the basal triangle at the root of the spine, 
the rhoniljoideus minor into the jmrt opposite the l>asal triangle, 
and the ihomlnjideus major into the rest of the border, by means of 
a tendinouH arch to which the muscular fibres are nttachoil. The 
serralus ratigtius is inserted into a special area nuining along the 
ventral surface of the scapula close to the vertebral border for its 
whide length, but, the fibres are much thicker at the upper and 
lower angles than in the middle. The small insertion of the pectoralis 
minor is attached to the itiner border and ujipcr surface of the 
coracoid process, the tiji of which process gives origin to the conw 
brachialis and the short head of the bicej)s. 

[A sniall block is now to be placed beneath the lower border of 
scapula so as to put the deltoid on the stretch, and the remainder 
its fibres ai'e then to be denned, notice l>eing Uiken of one or two 
small bnincbes of the circumflex nerve which tnm njuiid its pt>sterior 
bonier, (iiid of a few descending arrumial twigs from the superficial 
branches of the cervical pK-xus (Fig. 8, i) which supjdy the skin of 
the shoulder.] 



¥ 



me I 
tlJ| 



The Deltoid MuBcle (Fig. 1ft, 6) arue* from the anteri< 
fHjrder of the outer half of the clavicle and the adjacent portion 
the superior surface as far as the curved deltoid ridge, and from' 
the tip luid outer edge of the acrtjmion, and the lower liji of the 
siiiiH- of the scapula. Its strong coarse fibres converge to W 
innrrti-d into a rovigh V-shajX'd surface on the outer side of t! 
humerus above the midiUc of the shaft, and are embraced by th( 
bifid origin of the brachialis nnticus, and closely coiinectetl with thi 
insertion of the pectoralis major. The muscle is coarsely fa.«ciculated 
and intersected by tendinous bands, four of which above are attached 
to tubercles on the outer border of the acromion ])rocess, and tbre« 
below to vertical ridges on the deltoid impression of the humerus. 
Fig. 1 i will indii-«te the typical arnuigcnient of the fibnts, but many 
Tahstiotis are Jiiet witL. The adiim of the deltoid as a whole is to 
'•utwunlt the arm to the level of the shoidder, t.<., to abduct 






th^l 
th^l 
th«M 
ted"| 
I 



V 



J 



THE DELTOID. 



39 



hnmeruB ; but tLe anterior fibres will OKtist in Hexion and 
emal rotation, and tlie posterior in extension and exlenml 
ution of the shoulder-joint. It is supplied by the circiuiitlex 
nerve. 

[Tlie deltoid is to !>« divided neiir ils uri^in ami lurmd down, lla- 
ORUiutlex vessels and ntrve being preserved. In doiuy this a larjje 




bursa lyin^ between the deltoid and the slioulder-juint should be 
noticed. The remains of tho trapezius ninacle are to be cut close to 
the spine of the sc^ipiilii, and llie thin iiiscia covering; the muscles 
aljove and below it removed, the humerus bein^; rotated itiwards to 
put their fibre? on the streteh.] 

The Bub-acromial Bursa lines the interval between the upper 
l«rt of the shiiujdei-juiiit uiid the under surface of the deltnid, 
acroniion process, and coraovacromiid ligament. It thus forms an 
ext«m»ire foc, the enlargement of which luay be confounded with 
ditense of the joint. Physiologically it represents a synovial lining 



Fig. 14. — Pkn of the deltoiil (nflor Cunninghttm). 
XIpj>ertendii)ou8iut<"r»e<!ti(insiiri»- 5. Lompi- tcndiiiouR intenectiona re' 



inr fmni ooroinion. 




ceiving three of the upper «ej- 
ments iirtheniuncleand uuerted 
into humenifl. 



38 



PARTS ABOUT THE SCAPULA. 



ideiilifv again the wveral ins«?rtiou8of muscles on the BCapula, i 
each muscle about an inch Imm it# attachiuent.] 

The insertion of the trapezius extends along the upper lionler of 
the spine of the ecapula, the inner hoi-der of the acromion, 
the outer third of the posterior border of the clavicle. The o: 
hyoid arises from the upi>er margin of the scnpula close to 
nutih and from the transverse ligament. The levator an; 
scapula' is inserted into that jMxrt of the vertebral lx)rder of the 
saipula which is above the basal triangle at the root of the spinej 
the rhomboiilcus minor into the ]iart opposite the basal Irian; 
and tlie rhomboideus major into the rest of the border, by means 
a tendinous arch to which the muscular fibix-s are atttiched 
serratus magnuB is inserted into a special area running along 
Ventral surface of the scjipiila close to the vertebral horder for its 
whole length, but the filires aiv much thicker at the upper and 
lower angles than in the middle. The small insei'tion of the jiectoralis 
minor is attached t<i the iiinet bonier and upper surface of the 
coraeoid pi-<>ce«», the tip of which process gives origin to the coraco- 
brachialis and the short head of the biceps. 

[A small block is nuw to be placed beneath the lower Iwrder of tl 
Bca]iula so as to put the deltoid ou the stretch, and the renuunder 
its ftbres arc then to be cleaned, notice being taken of one or t 
small biitnches of the circumflex nen-e which turn round its pi^terii 
boi-iler, and nf a few desccndinj^ acramial twigs from the siipcrti' ' 
branches of the cervical plexus (Fig. y, i) which supply the skin of 
the shoulder.] 



;r of 

thc^ 
lineal 

thW 



The Deltoid Muscle (Fig. l."), 6) ariiies from the nnteri< 
bonier of the outer half of the clavicle and the adjacent portion of 
the superior surface as far as tlie curved deltoid ridge, and from 
the tij) and outer edge of the acromion, and the lower li]i of the 
spine of the scapula. Its strong coarse fibres converge to l.>e 
intrrtid into a rough V-shaj)e<l surface ou the outer side of the 
humerus above the middle of the shaft, and are embniced by the 
Inlid origin of the brachialis anticiiri, and closely connected with the 
insertion of the ixjctoralis major. The muscle is coarsely fasciculated 
and intersected by tendinous bunds, four of which above are attached 
to tubendes on the outer border of the acromion jirocess, and thn;e 
below to vertical ridges on the deltoid imj)rcsaion of tlie humerus.! 
Fig. 1 4 will indicate the tj'jjical amuigement of the fibres, but man; 
variations are met with. The action of the deltoiil as a whole is 
raise outwaj-ds the arm to the level of the shoulder, i.e., to abdtu 



io^^ 




THE TERES MINOR, 



41 



dissection of the axilla (p. 19), can now be neen from behind, 

the quadrilateral or outer spate will he fnuinl to he bouiuled 

; teres major, teres minor, lininerus, and long head of triceps ; 

triiui;;ular or inner space, by tlm teres major, teres raimir, and 

'iij head of triceps. (A triaiigutor interval between the tei-ea 

ni,i|Mr and the long and extenial heads of the triceps must not lie 

iii;-t,iken for this latter space.) The jioitteriur ciiruinHex vessels 

ui'l cir;uniflex nerve pa-is through the (lUiuirilnteral i»pace ; the 

il"t--ilis scapulas artery enters the triangular p]iace to reach tJie 

iiilr.\i~pinous fossa ; and the larf^e musculo-apiral nerve, with the 

bnichiul artery in front of it will be seen between the long and 

Ppter heads of the triceps, 
i The 8upra-apinatU8 Muscle {Fif!- •■''. 3) wcnpies the supra- 
Ijnnal foissii, urisinij fitini the inner two-tliiids of the fossa itielf, 
from the U]iiM!r hurfuce of the spine, and frnm the fiuscin coverin;^ 
I uncle. The t€nd<in passes beneath the acruminn to be inserted 
lie uppermost facet on the great tuberosity of the humerus, 
Iv inU) the cajisular ligament of the shoulder- juint. In 
M.iw the tendon thnroii<"hly, the acromial end of the spine 
ida is to be divided with the saw, when a part of the 
1 bursa, before meiitioneil, will be fuiuid between it ami 
(be muscle, 

Tlif Infira-spinatUB Muscle (Fig. 15, 5) •iriin-» from the inner 

inU of the infnispiiial fossa (the part near the neck of the 

y.uA being free from uuisi.ular attachments in all three fos-sie), 

from the fascia covering the mflscle, and fron; the internuiscular 

ta between it ami thi; tcrt-s nniseles. It is instrtal into the 

idle facet on the great tuberosity of the humerus ami into the 

b- of the shoulder-joint, 'leing blen<led there with the suiuu- 

' ns and teres minor. It is occasionally sejiamtetl from the 

!e by a bursa. The 8U|>ra- and infra-spinattw muscles are 

.<•/ by the suprascapular nerve. 

The Teres Minor Muscle {Fig. 13, 9) is closely connected 

with the infni-spinatiis. It iiriats from the upper jmrt of the teres 

an-4 u[K>n the dorsal aspect of the Kcapula, from the fascia covering 

111-. 1i', and from the intennusculur septa between it and the 

■lis and teres major muscles; and is ituerUtl into the 

; on the great tulwrosity of the hunierug and for nearly an 

it, and also into the wipsular ligament of the shoulder. 

\jr}tii':'{ by a special branch of the circunille.x nerve, which is 

lable for having an enlargement ujion it depending upon a 

bn{ of the perineural connective tissue. 

•upra-spinutus is an uMactor and internal mlatw, anJV l\w 




il,.- 




40 



PARTS ABOUT THE SCAPULA. 



to an accessory and extra-capsiilar Bhoulder-joint between the upp 
extremity of tlie luinierus liulow luiJ tlie hollow foTiiieil by the under 
surface of the ncroiiiioii iind toraco-ntroiiiial liyiiiiieiit iibove. 

The Parte beneath the Deltoid Muscle (Fir;. 15) are — the 
Coraco-iicToniiul liyiuiieiit, the t'oroeoid process with the miisclesl 
attached to it, the Siib-acromial Imrsu, the Infni-sjiinatiw, the Teres! 



' 




llinoT nnd Major, the long htad of the Tricoiw, the lu-iul and neck 
of the humctusi, the coracoid procws nnd the musclts altai-hed to it, 
and the circumllex vessels and nerve. The tiii of the contcoid 
process lies close to the inlerval between the pcclnralis major and 
deltoid, but i» usually <)verhip]>til by the latter. 

The quadrilateral and triangular inteniuistular apacesi, referred to 



I 



Fig. 15. — SopuUr niu«ile«, Tem<?l«, and ncrrpd (ftom Cnivei-sity C'oUpge 
Museum), 



1. Suprm-Kapulor nerve, 

2. Circumflex nerve. 

3. Supm-ipinstut. 

4. PMterior circumflex »rt«ry. 
6. Infrn-ipiniitui. 

6. Ueltoia (rcflccled). 

7. Tcrct major and latisiimuF. 



8. Bmcliinl ortery. 

9. Teres minor. 

10. ^luflcuIo-^pinll nerve. 

11. UurMilis acnpula' artery. 

12. Trieep* (outer liend). 

13. Tricepa (long bead). 



THE TERES MINOR. 



41 



^TIk- 



iu the dissection of thv axilla (p. 1 9), can now lie Been from bdiintl, 
wkea the quadrilateral or outer space will l>e fnund to be bounded 
by the teres niajor, teres minor, humerus, and long head uf triceps ; 
the trian^pilAT or inner space, by the teres major, leren minor, and 
lon^' heail of tricejw. (A triangular interval between the teres 
nukjor and the long and external heads of tlie triceps must not Iw 
mistaken for this latter space.) The jiosterior circumHex vessels 
and circumHex nerve jiass through the qiiaflri lateral space ; the 
domlis scapuUe artery enters the triangular syuice to reach the 
infmspinous fossa ; and the large niusculi^spiral nerve, with the 
hraizhiol artery in front of it will be seen between the long and 
outer hemls of the triceiis. 

The Supra-spinatus Muacle (Fig. 15, 3) occupies the supra- 
nnl fo*Sii, iiruriiuj from the inner two-thirds of the fossa itself, 
ni the upi>er surface of the spine, and from the fascia covering 
mu»:le. The tendon pa'wes Ijcneath the acromion to l>e insrrted 
into the uppermost facet on the great tnbcrosily of the linnierus, 
and slightly into the capsular ligament of the shuuldcr-joint. In 
orrler to follow the tendon thoroughly, the acromial end of the sjiine 
of the scjipula is to be divldeil with tlie saw, when n part of the 
suliacitjniial bursa, before mentioned, will be found between it and 
the muscle. 

The Inf^a-apinatus Muscle (Fig. 15, 5} (irM« from the inner 
two-thirds of the infraspinal fossa (the part near the neck of the 
wuipala being free from muscular attachineiit.s in all three foss(e), 
from the fascia covering the m(ls<-le, and from the intermuscular 
ita l>etween it and the teres muscles. It is hiserUd into the 
iddle facet on the great tuberosity of the Immerus and into the 
.psnie of the shoulder-joint, being blended there with the sujira- 
fpinatus and teres minor. It is occ^isioiially se]iaruted frtmi the 
capsule by a bursa. The supra- and infni-spinatus muscles are 
Mupplied by the suprascapular nerve. 

The Teres Minor Muscle (Fig. 15, 9) is closely connected 
with the infra-npinatns. It iirines from the upper part of the teres 
HK-a ii|K)n the dorsal a<ij>ect of the scapula, from the fascia covering 
iLe muscle, an<l from the intermuscular septa between it and the 
iniia-epinatus and teres major nuwclcs ; and is iHsrrted into the 
lowest facet on the great tuberosity of the humerus and for nearly an 
inch below it, luid also into the capsular ligament of the shoulder. 
It ia iuppluid by a special branch of the circumflex nerve, which is 
KOiATksble for having an cnlargcnicnt ii])on it depending upon a 
iLickeniiig of the perineuml connective tissue. 

The supro-spinatus ia an itMiulor ami intenutl rotiitor, (kT\i\ t\v% 



42 



PAHTS ABOUT THE SCAPULA. 



infra-9pinatU3 and teres minor miisclea are external rulators am 
(tMnftorn rif the liumenii'. 

The Teres Major Muscle (Fig. ]5, 7) arita from the lowi 
portion of the triangular terea area, at the inferior angle of the 
scapula, and from the intemuiscular septa between it and the teres 
minor and infrn-spinatue muBcles. Its close relation to the latissiinus 
dorsi has lieen iilreiidy noticed, but its ijuserttwii into the inner lip of 
the bicipital groove and the bursa between it and the tendon of the 
hitissimu9 should be again clearly seen. It is tuiiplifd by the lower 
Hiibscapular nerve, and is au adductor and hilenuil TOtutor of the 
humenis. 

The Posterior Circumflex Artery (Fig. 15, 4) with its veins, 
and the Circumflex Nerve (Fig. io, 2), appear through the 
ijuadrilatend space (see pp. tl ami 4U). The nerve is distrilnited 
to the deep surface of the deltoid muscle, and to the tores minor 
muscle (the branch [ircsenting the above uicnti'ined enlargement), 
and FUjiplies also tlie shoulder-joint, and the skin over the lower 
part of the deltoid and back of the arm. The posterior circumflex 
arterj' not unfre<]ueut!y arises from, or in conmum with, the superior' 
profunda, in which case it is below instead of aboie the teres mayoi 
It supplies the same parts as the nerve. 

The Dorsalia Scapulea Artery (dorsal branch of sulwcapular) 
(Fig. 1;"), I i), does nut pass tUrovigh the triangular space as seen 
from liehiuii, but winds beneath tlie teres minor in a grtxjve on the 
axillary border of the scapula, to supjily the infraspinal fossa and 
anosUimnse with the other scapular iirti'rie.s. It gives off a ventral 
infrn-sdiiniUir bramh, which will be aflervvanis traced beneath the 
«ub»caj)ulari8, and a sujierHcial branch, which runs between the 
teres major and minor and down to the angle of the scjipula, to 
anastomose with the subscapular and posterior scapular arteries. 

[Tlie supra-spinatus and infm-spinatua are t«i l>e ilivided near their 
insertions, and the muscular fibres cleared out of the supra-spinal 
fossit in order to see the supra-scapular artery and nerve and the 
origin of the omo-liyoid luuscie.} 

The Supra-scapular or Transversalis humeri Artery 
(from the thynjid axis) passes over the transverse ligament of the 
scapula, and is distributed to the supraspinal fossa, and also to part 
of the infnLspinal fossa by a branch which winds around the external 
bonier of the spine, and anastomoses with the donwdis scapulas and 
poeterior scapular arteries. Beforv crossing the ligament, it sends a 
tupni-iwromial branch through the atlacliment of the trai>e/.ius, and 
a tubtaipnlar twig to the venter of the scapula. 



er 



4 
4 
4 



THE SUBSCAPULAR NERVES. 



43 



The Bupra-Bcapular ITerve (Fig. 15, i) (from the anterior 
iches of the 6th and 6th cervicHl nervea) gives a branch to the 
toulder-joint anil jNisses throii(,'h the supra-scapular notch ujid 
iiieatli the ligament, to be distributed to the supra- and infra- 
piuutus must'Ies. 

The Omo-hyoid Miisole ariwvi from nhout ludf an incli of the 
uperior bonier of the scapula, immediately behind the supra- 
ftpalar notch, and from the transverse or posterior ligament over 
iL It>« relations and insertion are seen in the dissection of the 
neck. 

[The limb ib to. be turned over and the humeru.<* rotated outwards 
put the fibres of the sub.icapularia on the stretcli ; they should 

en be cleaned, care lieing taken oT llio sulvnuiiular ntTves eiiti-ntig 
muucle. The axillary vessels and nerves shurild be tied to the 
coid proce.is, so as to brinfj them as nearly iis may be into their 

oper positions.] 

The SubBcaptUaris Muscle (Fi),'. tJ, lo) is covered by a thin 
i-ia, and has been alreiuly seen to form ])urt of the posterior wall 
I oxilhu It iirufM from the whole of the venter scajmlie, except 
V^jtA to which the serratus niagnUB is attached niid the portion 
neareat the neck of the lione, ninl iius sevend tendinous septa be- 
tween it« fibres, which are attached to the rid^'cs uii tliu surface of 
the bone, and bear some resenibl.ince to those of tlie deltoid. It is 
iiutrted into the lesser tuberosity uf the luniierus and tin- bone below 
i for an inch, and into the capsular liyaiiient of the shoulder-joint, 
I lar^e bursa iuterv'ening between the muscle and the neck of the 
•pala, which almost always communicates with the aivity of the 
over the upper border of the tendon. The siibscapularis is an 
rotator and addttclor of the humerus, and is tuppli«d by the 
bort subscapular ner^-es. 

An ituportant action of the supra- and infra-spinati, teres minor, 
anil Buliscapidaris muscles is their combination to keep the head of 
the hunierus in its proper relation to the glenoid cavity, and thus 
prevent dislocation. In the jiost-mortcm relaxed condition of the 
s, the hea«l of the lnuaerus tan be drawn uway from the glenoid 
ivity to tlie full extent of the loohe capr-uliir ligunieiit. 
The Subscapular Nerves (Fig. 7) are brauche.i of the posterior 
of the bradiial plexus, and are three in number. The long or 
Je euliscajiiilar nerve has been alreiwly seen in the axilla, and 
be traced to the lalissimus dorsi ; the short subscapular 
(upper and lower) are now to I* followed, the u]ij>er to the 
nbacspolaris muscle, the lower to the subscapuhuis and teres u\vl^oi. 




pnl 



EcStiU 



H THE BACK OF THE ABM. 

Tlie Bubaoapular Artery (p. 19) is Ktill to be seen running 
along the axillary Ixirder of the scapula, and its branches should 
l>e thoroughly followed out. 

The Infra-Bcapular Artery ia derived from the dorsal branch 
of the siubuciijiuki' niliTV. It passes into the venter sonpulee, 
l>eneath the Bubscnpularia muscle, which must he divided to expose 
it, mid annstonioses with the neighbouring vessels. 

The Posterior Scapular Artery is to be found between the 
serratuH magnus and the rhomboidei, and its aiinstoniosea upon the 
dorsal and ventrftl Mirfaces of liie scapula should he detiiied. 

By reuiKvinj; the nHi>^cuhir fibres from both surfaces of thescapida 
a very ubuudanl network of vessels will be seen, foirned by anasto- 
mosing IjDinches from the arteries which have been already traced 
to the scapula ; viz., the subsc^pulur with its doi-mit bninch 
[axillaryj, the sujini-scapular [thyroid axis], and the posterior 
scupidar [thyroid nxi.* or subclaviaaj, 

Thb Back or the Arm. 

[The fore-anu and hand are to be dotiblcd under tlio upper arm, 
which is to Ih- placed on the table w ith the back upwards, and the 
scapula is to be drawn down with hook" bo an to put tlie tricejwj on 
the stretch. Wbcn ihi' skin ha.-^ Iiecn tx'inoved from the back of the 
arm, two external cutaneous branches of the tuusculo-spital nerve 
should be noticed.] 



n 

n 



I 



Cutaneous Werves. — The upper tr/cmoi cul<iiifot(.4 branch j 
of the )au.iiii!it-!>2iii(U (Fig. W, 7) appears about the middle of 1 
the outer side of the ami, and runs dowiiwanls and forwanls along 
the cephalic vein to the ujiper jmrt of the foa*-arm ; the lower 
txlmuit, of larger size (Fig. 16, 6), ajipears chjsc above the external 
condyle, and will be aflenvards triced ilown the back of the fore- 
arm to the WTist ; and the third or hilernu! culnneonii branch 
pierces the fiuscia near the tendon of the teres major and supplies on 
areo on the inner side of the arm behind that of the intercosto- 
humerid nerve (Fig. H, 6). 

Itrmiches from the inUniiil cnttineotu and letter internal eiitaruoui 
ner\'es will be found on the inner side of the limb, and filaments 
of the circiinijtcj- nerve run ehiwnwnnls over the Ijack of the arm, ^^ 
and upwards over the lower part of the deltoid (Fig. 16). ^| 

[When the strong deep fascia of the arm has been divided, the ' 
fibres of the triceiM mu.sde should bo cleaned, and a large bursa 
1)etween the triangular posterior surface of tlie ulna and tlie skin 
•hould be notice*!.] 



I 




THE TRICEPS. 



45 



The Triceps Muscle (Fig. 16) lins of course three heads — tlie 

Dg or luiiidle, Ibe extcninl, mid tl>e interiiul. The long (i i ) head 

fnim a $oniewlmt triaiiguhir rough surface on tlie axillary 

bonier of the scapula immediately balow the glenoid aivity. It 

ba» Ijeeu already partly e-x- 



i 



muiued both from the front anrl 
ini behind in relation with 
nain spaces (pp. lit, 4(ij, aiid 
fibres are now r^een to be 
paraled by another somewhat 
iriaiignlar interval from the 
l«ck of the upper thinl of the 
hamenu, until it joins the ex- 
lal heoil at tlie junction of 
iC upjier >»ith the middle third 
bune. The outer head (4J 
from immediately Itelow 
insertion of the teres minor, 
(1 from the outer side of the 
isterior aspect of the I)one, ns 
down IIS the mu6culu-s]iiral 
e; also slightly from tlic 
1 intennuscular septum 
which intervenes Ijetween it and 
Uie deltoid. It forms a teu- 
lous arch over the musculo- 
■pinil nerve. The inner head 
(ij) arite* from the whole of 

Fig. 16. — Di*vcti<in of back of upper 
arm (from Hirsclifpld aod LeveilliM. 

• 1. Infni-ipiuiitus. 
2. Deltoid. 
3. Terrs minor. 
4. Outer lieiid of Iriccps. 
6 Cirtuiiitlfx m-rvf. 
6. Estemnl luoneoua branch of 

Imuicu1o-s]iinil nerrc. 
1 7, Terei iimjor. 
8. Supinotnr loiipi*. 
a. Mu»rulo-«iiiinl nerve. 
10. Kttciisrir nirjii ndialis longior. 
11. Middle hrnd uf triceps. 
I'l. AnconruD. 
13. Inner biiid of triceps. 
IS. Ulnar nerve. 



Tig. 18. 



^U»e 
■litu 




46 



THE BACK OF THK ARM. 



the posterior nspeet of the humeruB below tbe insertion of the 
teres iiinjor and the musculrj-spiral jjroove, to witliiii iuilf an inch of 
the elliow-jdint un the inner siile, and extending tn the Imck of the 
condyle on the outer side : tibres also arise from the external and 
uiteriial intermuscular septa which inten'ene between it and tnuseles 
of the front of the ann. The whole of the tihrea converge to a 
strong tendon, which is iiuerkii into the iiopteiior margin of the top 
of the olecranon process of the nlna, and into the deeji fascia of the 
fore-ann by means of a strong jindoiigation, whicli lies over the 
anconeus muscle, and is tixed to tlie posterior border of the ulna ; 
while a fttsciculiLs detached from its deep surface is attached to the 
back of the capsule of the elbow-joint, and is known as the ttth- 
ancontia. A small bursa intervenes between the tendon and the 
forepart of the olecnuion process, which will be seen when the joint 
is opened. The triceps is the great rxlrnsor of the fore-ann U]mhi the 
npjKT arm, aiul its action m that of a force a]i]ilitd to a lever of the 
first order. The Imig head al>o adducts and draws backwards tbe 
humenis. It is tiipjitied by the musculo-sjiiral nerve. 

[The long head lieing hooked to the inner side, and the musculo- 
Bpind nene having been ]mt on the stretch, the fibres of liie outer 
head are to be divided as they Idend witli those of the inner head in 
order to follow tlie nerve, with the sujierior profunda artery, roimd 
the bone.] 

The MuBOUlo-epiral Nerve (Fig. 1 G, 9) has lieen already shown 
(p. 3.t) to lie a branch of the posterior cord of the brachial plexus, 
and has been seen to disapjieur Itetween the interna! and middle 
heads of the triceps ; it am now be followed in the oli!i([Ue groove 
on the back of the humerus between the inner and (inter heads of 
the muscle, until it reaches the inteiTal between tin; supinator 
longns and brachialLs anticus. It gives off numerons hirge liranchea 
to the triceps in its course, ami afterwards BUjiplies the supinator 
longiis, extensor carpi radinlis iongior, bracliialis anticus (in I>ort), 
and the anconeus ; imd the branch to the last muscle with an 
rtccomiianyiiig artery should be at once tracrd through the libres of 
the triceps at the liuck of the external condyle. The branch to tlie 
inner head of the triccjis is known as the iihiar rnUatenil of Krause, 
beaiuse it descends in close relation to the ulnar nerve. The cuta- 
neous branches liave been describt-d at p. 44. 

The Superior Proftmda branch of the brachial artery accom- 
jMinies the luusculo-sjiiral ner\e around the Isme, and supplies 
the triceps in its coiirxc. lieueath the muscle a branch ascends t<i 
anastomose with the i>o6terior circumlle.\ artery. At the iimer 



I 

I 



THE SUPERIOR PROFUNDA ARTERY. 



47 



' of tLc triceps it gives off a rather liii^e Viraiich, the iletcfuding 
ficnlnr, which runs down to the Iwick (if tlie ellxiw benenth the 
. close to the external intermuscular septum to una-stomoae 



Fif. 17. 




irith the posterior interogseous recurrent anil with tbu aiiustonmtic 
anil inferior jirofunila arteries. The lermiunl hrniich, iisuiilly of 
snmll size, niiis with the nun'e between the supinator longus ami 
brachialis anticuit to anastomose with the radiul recuiTeiit artur>'. 



Kg. IT 



8. Musi'iilo-apiRil nerve. 

9. liunilic vein with internal cuta- 



A aection through the niiililtc «( the right oppcr nnn (nltvreil from 
Beruuii). 

Biieji*. 

Cejihiilic vein. 

Bnehiiil resseln. lu-ous nerve. 

Mu8i:uli>-tutAne<ius Der>'e, 10. Suiieriur profunda ve>*M'l8. 

Median nerve. 11. Inferiur inofuiula ve»*eU. 

Bt*cliiali* aoticu*. 1^. Trieepi with tilimus intersection. 

Ulnar nerve. 




w 



THE FHOMT OF THE FOBE-AKM. 



The Front of the Fore- arm. 

[One incision is to he made down the niidille of tho fore-arm, and 
aiuitla-r at ri^'ht angles to it ncrosH [Iw front of tlie wrist, and the 
flaps of skin ok hi b« turnud to each side,] 

The Cutaneous Veins ( Fig. 

18) will lie I'rpiiiid in the super- 
ticiiil fascia, and can be delined 
without injury to the nerves. 
The Anterior Ulnar Vein (lo) 
U pretty rejjuliir in it*i course, 
inid will l>e found lu commence 
in one or Iwii srniill branches 
alHUit the inner side of the wrist ; 
then running along the inner 
side of the fore-arm, it joins the 
I'liAtfrinr Vlmir i'tiii (8) near 
the elliow, and iLssiatJs in forming 
the liiwlic vein. 

The I'lmtrrCur Ulnar I'ein 
arises from the inner fide of the 
dorsal jdexus nver the 3nl, 4tli, 
and Tith nietacarjiul hones. I 

The Mt:iti>iit I'ein (9) com- 
mences in front of the wrist neor 




Fig. 18. — Cutaneou* Jiniection of the 
frtiiil of the forc-irm (from 
Hirm'hli'ld and Lcvcillc). 

1. IVplmlic Tidn. 

2. Itinilii' vein. 

3. ExtcrunI culnaeou* branch 

iuum*ul«-«iHrui ni-rve. 
•1, Interim! lutnacouit nerve. 
6, i. Kxterrml cutanentm nrrro. 

6. Deep vein joiiiini; the bifurcation 

of the inittLan. 

7. Radial vi'in. 

8. Po»tcrior iilnnr vein. 

9. )Ie<Ii»n vein, dividing into nie- 

dinn-hiirilio and meaian-oepha- _ 
Ho reinn. 
lU. Anterior ulnar vein. 

1 1 . Kadiiil nerre. 

12. Cutuneout bniorh ofuhmr nerve. 
14. r«lmiir branch of mediao acnre. 
16. i'alinarif brevia miuele. 



DEEP FASCIA OK KORK-ARM. 



49 



tbe mot of the thuin1>, oouwing obliquely to the centre of the limli 
near tbe bejiil of the elbow, where it is joiiieil by the profunda 
v-cin dUil divides into medinii lioiiilii; nml iiiudian cephalic branches 
(p. 27}. 

The Riulial Vtin (7) commenoej- at the bark of the Imud from 
the iiiiUT siile of the dorsal plexus, and iipiiears on the radial aide of 
the furv-arm about \\i> middle. It hits been seen to unite with the 
inoliiKi i-€plinlic to fonu the c^'jihalii' vein (p. 27). Besides these 
iiauied vein.s tliere are iiuinernus smaller brunches which tuuist, and 
• ■ccacitiiwlly lake the place of, tiio larj^er ones. 

Tlje Cutaneous Kerves (Fig. 18) are now to be followej 
«.ul. .' v^ 

The JafiPiiil nittiwnnt netve (4) can be troccl to the whole of the- , 
iuner siile of the fore-arm, the branches win Hnj< roviiid to thfe back/. 5 
■ if till- limb. It sometimes forms n juiutiou willi llie fullowiug^ — « 

The fudiiuir cutiiueoin hnairh iif llif Ulnar iwrir (12) may be 
found pierein;- the fa-scia alxiut a hand's breiullh al)ove the wrist, 
ili>M' to the ridial edge of the llexor cjirpi ulnaris tendon, and 
tmced tu the alnar jide of the ]ialni. 

Tbe Kjirrnul cutniirnii.^ (niti.siulo-eulanpous) rcri'iJ (5) is distri- 
\AXtei\ to the iiidial siile i^f (In- fnre-arni by two bnuiche-s : — the 
•intorurr, »cconi]>onyiii^ the ntdial vein, is distriJnited on tlie anterior 
.ui(»>Ct and ends on the Indl of the thumb ; the ;w.>YtiiW reaches the 
Iwck of the foiii-arm, and, after joining '''t* radial nerve, ends at the 
Iwel of the wrint. 

The jHilmoT '■Hlmeous Immdi 0/ thr Mmlian n«rve (14) pierces the 
fancim in the centre of the fore-arm alx>ul two inches above the 
vrUt, and jm.'-ses to the ]>alm of the linnd, eomniuiiicatin^ with the 
{nlioar eutaneous liraneh of the ulnar. 

The Deep fascia is now to lie elenned, and will be found to be 
<»iiiiniioii.>) with the deep fascia of the arm above, and with the 
iiuualur ligament below. It gives off intermuscular septa which are 
atUehi;<l deeply to ri<lges upon llie radius and ulna, give origin to 
nnKoliir fibre.*, and fona sheaths for the muscles and tendons. 
In n thin subject the.se are seen as white lines, running moi-e or 
I"* in the direction of the long axis of the limit. 

[The muscles arising from tlie itdernal condyle are to be cleaneil 
■i> f«r tt-s possible without disturlnng thmi ; a small part only of the 
llnur suUimis will be tlius exposed. The e«ige of the siijiinator 
lpn;;M» is also to be 1 leaned. The radial artery iiiust be shown 
llitunuhout its eour*'.', and the ulnar artery near the wrist at the 
'*li«r side of the tcnilon of the lUx^'r mrpi idnaris. The niediim 
wnc will appear between the tendons of the Hexor cat\t'i tuAvivWs. 
'inil llcxor sumimis, ami to the- nidinl tide of the laller.l 



50 



THE FKONT OF TUE FOUE-AKM. 



The Muscles (Fig. lit) arising froui the inner condyle are fi^ 
in numluT, four bt'ijig flrxiir> of tlie corjms anrl fingem, and on<i 
it prnnalnr of the fore-iirin. He(;inning from the outer nide, tliei^ 

vi-liiti^c pofitinns are: — 1, J)P 



Fi(t. 19. 



imtor tens ; 2, llexnr carpi m- 
iliaiis ; 3, pahiiaris tiin;;us (which 
may he al)fi'nt) ; 4, Hexor *ul>- 
liiiiib tligitipiiitii ; 5, Hexor carpi 
iiliiaris. Ail thofe iiiusiles have 
a coniiniin origin frfim (1) the 
intenial condyle, (2) the fo^ciu 
iif tin- fiiiL'-arni, and (3) the 
intvniiuwndar septa derived from 
it ; hut three of them, vi;e., the 
pronator teres, flexor sublimis 
(ligitoruni, and flexor ('urpi iil- 
naris", have exlni bony attach- 
metits. 

The Pronator Radii Teres 
(Fig. li), &) uncr.i from the inter- 
nal condyle alwve the other 
nuisclei-, and fnim half au inc 



■ \ w 



Fill, 19,— Suporlic ill! rliMei liun of forc- 
iirin nnil liand (frufii lionamj 
unci lU'nu). 

1, DicepH. 

2. Inner head of trit-ep*. 
•f, HrarhiHliii nnticus, 
■*. lirncUisil urterj*. 
'k .Suphintnr lon^iis. 
(1. Intcniul ronilyl". 
7, Flexor earpi rjctinliH. 
M. I'mnHtor radii tercn. 
H. lt;idiiil jirterj-, 

10. lliripitui rawia. 

1 1. I'li'.vnr luni^uii pollicU. 

12. I'lilniuriH joii^us. 

13. E.\teii8iir ossis ni(>tiiriii'pi poUiria. , 

14. FU'xnr saMimii' iliRiloruiu 

li). Kiten.«iiprinii inti-rnwlii |>ollici(.- 

Ifl. Flexor earpi uhmrii'. ' 

'7. SuiKTfiikl volur nrtory. 

18. I'lnur HI tery. 

1!). -Vlxlui'tor pultiiis, 

20. .Vntf rior nnimliir li^anieiit. 

21. Flt'ior tirflvi^ iMilliciis. 

22. Musote* of iitrle fioKt'r. 
21. Supei-ticinl p.ilinnr iirc'ii. 



FLEXOH CARPI ULNARIS. 



51 



^ran inch of the iujira-comlvlnr riilge : from the fo-scia of the fore-iirm 
over it ; niul fn>m thu inlcriuusculur septum lietween it iind the Hexor 
cjrpi rndinli* ; ami by ii second liciid from the ridge on the inner side 
of ibe coronoid process oJ fhe iihm below the \ilnar orij;iii of the 
Hexor sublimis. The median nerve lies between tlie two heads, the 
iihiar nrterv lieuealh tbeiiL It is iii»ertid by a broad temion into 
the middle of the outer side of the nulius, iininediately Indow the 
•upinator brcvisi. It pronates the baud by rolling the iiidiusi on the 
ulna, and dexes the elbow ; and is tupplitd by the highest branch of 
tlie median nerve. 

The Flexor Carpi Radialis (Fig. 11), 7) ari«* from the 
internal ctmdyle in coiiiinou with the other niUBch'.s ; from the fiiscia 
of the fore-arm; ami from the interniiiscvilur septa between it nnd 
the pronator tens* on one side, and the ]«dmari« longus and llexor 
sublimis on the other. It etuis abont the middle of the forearm in 
abroad tendon, which soon becomes rounded, ;ind ilisiippi'iirs at the 
root of the thumb, jiiercinj; the external iittaibmenl i-f the annular 
ligament and parsing through the gr(»>ve in the iraiieziinii, to be 
iMrrleii into the base of the second, ami slightly into llie luise of the 
thi»>l rnetftcariial bone. It is a flexor, an abductor and a pronator 
ufthe liJUid, and a slight flexor of the elbow. A.-* a tlexor nl' the 
wrist it nets «]ion both the radio-cnrpal and intercarpal joints. It 
\i$Hpplifil by the nieilian ner\'e. 
The Falmaris Iiongus (Tig. lil, i2)rtri«v< from the common 

f:hment to the inner condyle ; from the fascia of the forc-arra ; 
from the intermuscular septa on each side of and beneatb il. 
lon^; and narrow tendon passes su|>eitiii>illy to be iiu^n-lnl into 
tbt annular ligament, and terminates by cxpiuiding into the radiating 
r«lmar fascia in the centre of the ban<t. It serves to make tense 
(he p«lmur fjuscia and thus protect the deep structures in the palm. 
It dightly flexes the hand and elbow, and fixes the annular liga- 
ment during the action of the thumb luul litlle Iiii;;er. It is xup- 
\'M by the median nerve. 

teThc piilmaris longiis is subject to great variations ; it is freipiently 
Bting, but is sometime.s largely developed. Its muscular belly 
ly be displaced downwards to the middle or lower part of the 
fiii»-arm, or may be double ; and there are many irregulai-ities in 
I iii5*rlion. 

, Tho Plexor Carpi TTlnariB (Fig. in, 16) oriw* from the 

Bimoii attachment to the internal condyle, fmm the fascia of the 

inn, from the intermuscular sejitum betvs-een it and the 

^viaA muscles ; and by an additional aponeurotic origin from 

ianer side of the olecranon juocc*? and from the m<\iei" Iwo- 



52 



THE FROM' OF TliE FORE-ABM. 




(liinln of the posterii.r ridge of llu- ulnn witli ihc flexor profuni 
iliRitnnim. Tlie nmade is iutriieil \iy a Hatletu-d ti-itdoii (uj>oii 
wlikh the nniscular Kbre* extend nciirly to the wrist) into the. 

[lisiriinii Irane, whence it is pro' 
longed by li)jaiiieiitoii8 bands ti> 



annular ligiunent niid into tli<- 
Fip. 20. 




the unciform ]n-oces8 and boso 
of tlie fifth mctacarjial bonf. 
Tile ulnar nene enters the fore- 
firm between the two origins of^l 
this* uiuscle : the dorsal cufa-^ 
neou» branch of the ulnar wind.« 
beneath it in the lower third 
of the fore-ami, and the ulnar 



Fig, ?lt.— .SiiinTttcialdiwcrtion of the* 
frmit nf thf fore-arm {tram 
niralifi'lil nn<] LcTptlh'). 

I. Suiiiniitor l<;ii)nM (nit). 

J, 2. Ulnar npnc. 

.'). lliicps. 

4. id'dinn tK*nV'. 

j. Muaculn-tpiral iier>e. 

(*. Itmchinl artery. 

7 Posterior intff(>8M'«u» iirrre. 

8. I'loniilor ten-H. 

B. Supiniilor brvris. 

10. VIdht nrlen*. 

11. U. Iladinl licrvt-. 

12. Flexor onrjii mdiuli!* (mt). 

13. Eilcnfor inriii riiilintis liDinur. 

14. .\iitiTior iiUerojtueouH npn*r. 

15. K.\lenrtir rnrpy mdiattii bn-viur. 

16. Flt^xor Hiildiniiii digiloram. 

17. 17. Itiidiril nrtcry. 

18. Flfxor prnftindciHdt^itoniiii. 

19. Tendon of ]iroiutt<)r terej*. 
-0, Tendon of riexor rnrjii ulnnriit. 

21. 7'endan of Biipinator lon^». 

22. I'Inar artrry. 
'23. Flexor longu!i polliciii. 

24. Tendon of jidliiiiiriK loii^ua. 

25. Median uerv*», beroming super*! 

Kiinl. 
'Iti. Supertif-liil divUtnn of ulnar nerv 

27. 'I endon of flexor lai pi ladinlis. 

28. Deep hnoipji of tdiiRr niTve. 
2y. Ahddctor pollicii. 

.'10. Cutaneous pidmar bmuili <if iur> 

dian nerre. 
31. DiL'itnl branches of median nrn'C 
.32. Pnlmnris brfvis. 
'i4. SupeiHcitil p<itri>iir an h. 
36. I>igitnl brnmhes of ulnar nenc. 



THK IlADIAl. AKTKKV. 



58 



•}% «tul nfn'c lie In-iieiith tli«) jiriffw 'jf inneiliijii inin tin 

tuulur li|{iuiu-nt cliwi- to llu' nulial >iiilf of the li-ixlon ui-ar thi' 

i»t. It is the iiiih' iiuisc]r inMtrtrtl Jirfotly into otic of tlie ittrpiil 

iDvA, An>l i<^ (X tli-\nr of thi- eurjiiix ntiil of the cur|H>-mi-tiu'iir))fll 

tint of tho littl(< ringer, an otldiiotor of the huud, and iiwii the 

•ifonu buhe and Hniiitliil' li>;aiuvnt during' the actions of Uie 

^UM-Uv of the little fln>;i'r. It W gitpfilini hy llio nlliar niTvi-. 

The R&dlal Artery (Fig. 1», 9}, the mn«ller of thu divUion* 

tlie l)mi'liiid ortt-ry, extetuU in the fori'-iirin from tlic liifuri^alion 

tlic U-nd of the idUiw to the fi-ont of the tlyhiid prociiw nf the 

iiu». It i« HupiTlii'ittI in thi- whole of this coume, excepl when' 

ia moil* or Icvw oM-i'luiiiH-d hy th<> >upiniiti>r lon^iift mii«clc. It 

Ulvim the Miijiimitor longUH and tho ]irim«tor tort's above, 

id in the lower luilf of the fore-iinu Uitwwn tho ii'ndon* of 

be siipinator lungu* und llexor i^urpi rndinlix, which Utter ti^idon 

here (senumlly tukcn a* the ({wide to the veKMel. To it* nuhr 

i» thn nidiid nerve, which in the up|ier Ihinl of the ftnn i* at 

bnii* little diktance, in the middle tUinl itometimefl toticheit the 

■tery, and in the lower third ipiitu the vctmel ultogetlu-r to |«u»« 

enratli the HiipiiiHtor lnngu«, lU-nnitlt the ruiliul artery ure(l: 

lie tendon of the lilcc]m (if Ibu bifiircnlion tAkon |dni!e in the 

linar}- jxwition) ; (2) the Mipinator bn'VJM ; i',3) the iiwertion ol 

tc pronator Ictcb ; {i) the niilial origin of the (luxor Kuhlimi* ; 

i) the flexor longMK |Mdlicii> ; (tl) the pronator iiiindmtii« ; and 

J) the irii.i of the rndiua. It hu.i two veniB coinlteit nnd give* 

' the (ollowin>{ lirnnches : — 

Branches. — I. The iiuiial tfcurrmt (Ki)». 21. g) nin» ontwardx 
(m-nlh the supinator hinKun nnd jjive* iwcendin)- and deitcendini; 
jK-hes, the former anaHiomo»inf{ with the termination of thi' 
Ipcrior profunda hranch of ilie bruehial artery. 

i, ifuiaUar brancht* are given ulT at varloaa iK)intJi to the odjurent 
Itwlea. 

3. The tnittrficial Mar (21) anncB near the root of the thuiuh otid 

1 of varialile nize. It rnnn forward, ami Kenerally l»enoath some of 
be Bhrv* of the alidnct<ir pollicisi, tu complete the iiu{wrflciul palmar 
ch formed by the ulnar artery. 

4. The anterior cnrjint U H mnall branch which nilw ftcro«« the 
i»t beneath the deep Ivuilonn, to join a corresponding; branch of 

ho ulnar nrtery ot the level of the hiwer border of the pronator 
tdrutna. It annMomogteii witli twi}^ uf lh« anterior inturoojKotu 
ad deep ]i»lniar areh. 

Surgery. — The radial artery is readily tied, about an inch alxjve 
be wrirt, by an ini-iainn one inch and a half lon^;, placed mid- 



.54 



THE FRONT OF THE FORE-AKM. 



way between the tendons of tUe flexor corjii raitialis and supinata 
lonjius, wlieji till; ves?el will be found lying iuinieilifttely beueiith the 
deep fusciii, witli the vesiaj cumites in close conneiticiii l>»t with no 
nerve near it. The aiteiy niuy be t'X]ii>Kcd in the uiijicr ]>iirt by an 
iui'isiiin, two inches long, at iiny jtoinl in u line ilnvvn I'liun \hf 
centre of the l«'iiil of the elbow to the front of the styloid jiroeeKst of 
the ladius, the knife m>iiit; at once down to the supinator Kmpis, 
whii-h niu^t then be carefully turned outwards. The position of the 
nidifd nerve to tin- outtT side, in the middle thlixl ol the fore-arm, L-* 
to be borne in mind and the li;;ature pas,-<ed from it. 

When the radial artery is tied, the cirtulatinn is mainly earrie*! on 
by the ulnar anil it« branclie»<, the aiiaslonioses through the ]>aluitir^_ 
arches being veiy free. ^M 

[The jjionalor teivs is to be divided about ita ndddle, without 
injuring the median nerve or the ulnar origin of the nnisi-le, which 
ran now be ihorimghly seen ; and the llexor caqii radialis and 
palniaris longus are to be divided no as to ex[>ose tlioro\ighly the 
flexor siiblinnsjWliieh is to lie cleaneii. The skin of the front of one 
of the tiuj;er.s i» to be carefully removed without interfering with the 
jialni, and the sheiilb of the tendons dissected out (Fig. 20). Branches 
of tlic median nerve will be seen loenter the jironator radii teres, the 
|ialiiiaris longus, the Hexor subliiuis and the flexor carpi radialis ; 
the diL^ital vessels smd nerves on the- side of the hnger dissected must 
Ik- preserved.] 



I 



The Plexor Bublitaie Digitorum {jierforatun) {Fig. 20, i6) i» 
the only iiuiscle of the fore-arm whicli has its origin from the three 
Iwines (if the ana. It ((ri«.< from the internal condyle of the humerus 
and slightly from the internal lateral ligament cd' the elbow ; from 
[he iiitermiwcukir sejsta between it and the motx' Buperticial niuacles ; 
from a tubercle on tlie inner side of the coronoid process of the ulna 
aljove the pronator tere-s origin ; and from the whole of tlie obliijue 
line on the front of the radius and jiart of the e.xternal border of thi.* 
Iwne. Between the radiid and ulnar origins passes the median nerve. 
The muscle end* in four tendons, the two to the second and third 
lingers lying in fntnt of those to the first and fourth fingers, and 
all pass under the annular ligament and through the jialni of the 
hand to the second iihahinges of the four lingers. The tendon to the 
little finger is often of very small size. 

Til expose the insertion of the muscle the shcnih of the finger 
tendons should be laid oj»en along the centre. The sheath is 
fonaed by the bones and joints of the digit, and by a fibrous struc- 
ture, the liijavuriUum riitji iinlr, which is attached by thick and strong 
transverse lialids to the latend ridges on the first and secimd pha- 
liuigCB, and by tliinncr eximnsions to the ligaments of their articu- 



4 




FLEXOU LONGUS FOLLICIS. 



55 



ioas, soiuc of iu tilirt-s i1r(!iiKsntiiig diagonnlly across tlie front of 
thf two interpbnlangeal joints. The sheath is lined )<\ a synoviiil 
meiubraue, which it reHeolcd upon the tendons and forms certain 
little m-ces«)ry structures called rimrulti i-ateiiloxt. These are of 
two kinds : (1) long thrt-jid-like bonds jdissing downwaiiis from the 
phaLuigt^ to the tendons of the liexor subliniis and flexor jiro- 
lundiis, liiitiiiiriitii lomja ; and (2) short folds, one at thi.' insi-rtinn 
"( each tt-ndou, lit/niiieiita breria (Martliall). The tendon of the 
!-ubliiui» (perforafnf) will be Keen to divide on the first 
iiuix to give posrii^je to the tendon of the Hexor profundus (per- 
ns), the two slips uniting l>eneath the latter and dividing again 
i«(trrfr(/ into the ridges on the shaft of the sei'und phalanx ; 
while the tendon of the tie\or ]itvfiii!du.-< runs on to the base uf the 
ird pliulaux. The tiexor sublind.-' is a Hexor of the middle and 
Dxinial phalanges and of the carpus ; and is also a weak liexor 
Ttiie elbow, but its chief action is upon the phalanx to which it 
I attiicboil. It is tupjilifti by the luediaii neri'e. 
The position of the ulnar arterj', between the tendon oi the Hexor 
pi ulnnris and tlie innermost leiicbm tif the liexor subliniis in the 
half of the fore-arm, is now to lie noticed, and, by a slight 
lion of the tendons, the ubiar nerve can be seen Ij'ing clos«3l 
ulniir side of the arterj-. This is the point whei-e the ulnar 
ery is iisiudly tied. 

[The tiexor sublimis is now to be divided near its ongin and 
led down without injuring the median nerve, from which a 
ncli may be tniced to the dee]) surface of the muscle.] 

The Deep Muscles (Fig. 21) of the fore-arm are the flexor 

ngus jxdlicis on the radial Ktde, the flexor profinnhifi digitonim on 

ulnar side, and the pronator c|uailratus, a small .sipiare muscle 

"«ith transverse fibres, to be afterwards seen above the carpus by 

ilrawing a.Mde the tendons. These are now to be cleaned, all vessels 

luid ner%e8 lieing carefully picserved. 

The Flexor Iiongus Follicis (Fig. 21, 15) aTtue* from the 
whole of the anterior .surface of the radiiia between the oliliipie line 
Mid the attachment of the ]ironator (piudratus, and from the outer 
If of Die interosseous meiiibnine in nearly its whole length. 
generally has a small additional origin, by a slip of variable 
from the inner side of the coronoid process of the ulna, 
he tendon, invested by its own bursal sheath, pa-sses Iwneath the 
nnnular ligament, and through the pnlm nf the hand between the 
ro heads of the liexor brevis jioUicis, to l>e iiintrtal into the base 
the terminal phalanx of the thumb. The /i'yifjiicHdnii ruijiiavU 





THE FKOXT 



THE FOUE-ARM. 



of this U'liiliiii is much wvaker tbnii tlnj^e uf the Irnger teiidoni«, tuxl 
its sjnioviul lining is couinionly cojitinuous with the outer carpiJ 
bursa. 

Tlie Plexor Proftindus Digitorum (jwrforong) (Fig. 21, 34) 

tirisrn from the niiterior surface 



Fi§. 21. 




of the ulna K-tneen the uiscr- 
tion of the hnichialis anticu!> 
(which it cnilirncejii) iind thi- 
origin of the i>roniitor (lUttdratus; 
from the udjiioeiit half of tliv 
iiiteros-seuna niciubranf ; and 
froni the tipper two-thirds of 
the inner nurface of the ulna, 
extending to the coronoid and 
olecranon processe-s, and to the 
IHJsterior liorder of the bonr. 
The inu.«cle ends in four U-ndons 
(that to the index lingei- alone 
lieing i(uite *e]mrate in the foiv- 



I 



Fif. 21.— Deep diMoctiou of forr-ami 
iind bniid (from Itannioy anil Beau], 

1, Bircpg. 

Iiiiiir lipnd of liicr|». 

rira>hi:ili!i loitirut. 

Urn hi;il «rl*Ty. 

ltiri|ii(iil riiiu'iii. 

\nuft<tiit(vtii' artery. 

Sujnrmtiir lim^ruit. 

IritiM7uil conilyU'. 

Itiiiliiil nturri-iit iirterr. 

.iti(L'nor ulniir rwurreht art«rv. 
H. Itnliiil arlery. 
12. I'lisltriiir uliinr riiiirrcnt nrtci v. 

lii«i'rtuni u( pr^iiutur riidii ter»*». 

I'liiur iirit'i-y. 

Flexor IntlffuR imllirlH. 

Sui'iimtor Tirevin. 

I*rof)ii1or nuKdmturi. 

IiitiTo«M>ou* artery . 

Exlftwini of tliunili. 

.iiilerior )ntertift<*coUA artery-. 

Suierncinl voLir nrtcry. 
•i2. Flexor <iirpi uliinrU. 

23. .\l.du('t(>r iHdlins. 

24. Flexor iiiofunduit dif^ikirum. 
2>. Dii'p I'ulnmr torli. 

20. .\iiterinr iinniiliir lifpinicnt. 
28. Short muacleii of liilln linger. 
:iO. Suprrtiriiil piiliiiiir nnh. 



:s. 
J. 
.1. 

6. 

8.' 

9. 

10. 



13. 
14. 
Ifi. 
19. 
17. 
18. 
IS. 
20. 
.'1 



THE ULNAR AKTKRY. 



ai 



i), wliicli pass Ijencatli the annular ligaiuciit, ntul after living 
origin to the lumbricales muscles in the palm, pierce the tendon* 
of till- tlexor siiblitnis oppusite the first phahuiges, ami are itixrted 
into the bo.'^es n( the third phaliin;ies nf the four lingen«. 

The two prece<ling muscles are direi't flexors of the thumb and 

hng«r», und of the carpus, acting cliiefly ujion the tnininid phii- 

^Jugue. The flexor lungux ]iollii'ib hsKpiiliai by the niitc-rior iiit^^'r- 

^Vbbmous branch of tlie median nerve ; the flexor profuiidiin ]>aj'tly 

r l)y the anterior interotiseout branch of the median and jwrtiy by 

llie ulnar nerve. 

[By «epantl)ng the flexor longas ])olliciii from the flexor profnndiiR 
• lil'it"nifn, the intc«»'«eon!t vessels nTid the uiiti'rior interoHseoun 
M -i^i 1< and nerve, as well u,« the prmuiloi- iiimdrutus iiiiisck', will 
lie di^Jdayed.] 

The tendon? of the sublimiB and jirofundus are ]irovided nnlh 
I'lirtuI thfiillif coiumon to the Iwo ; a rur/ui! ^h^'alil lyiu^' In-neath 
ihe ontfrior ligament and extending >i little above niid bidnw it, 
.ind fiiffilal i<heathF, one for eJieh fin^'er, Iviny within the theca, 
■ind exti'nding moi-e or lef.B into the palm lii-yoiid the proximal side 
of the ligamentum vaginale, expi-iijdly in the case of the little 
finger, the digital (iheutli of whirh ciften riimiiiuniaite» with a distal 
alen»i'>n of the carpal i<!ieath. Thi' bursal alieatli of the thumb 
tendon comiuonly extends from above tlie annular ligament to the 
'lintol joint, but is occasionally divided into two parts by un interviil 
•ijijMiJiite the melocariml bone : iu lure cases it communicatea witli 
the cAryiol 8heath« of the finger tendons (Fig. 34). 

The Pronator Quadratus (Fig. dl, 17) is the only muscle in 
the arm whoHe fibivs an; transverse. It rtri*rx from the lower 
"liliipie line on the front of the ulna, below the origin of the 
dexor profundus, and is in^rrlnl into the wliole of the front of 
llie railiu>< below the attachment of the IK-xor longns jiollicis. This 
Uitisclc i» a powerful pronator of the I'ore-ann, and is siifi/illrd by 
lltt- anterior interosseous bratioh of the mediiin nerve. 

Tb<- Ulnar Artery (Fig. '21, 14) ari.ses from the bifurcution of 

be bnichial ai t<-ry at the lieinl of the elbow, and at hrst takes au 

'ililii{ue coursi? iuwanls linimtli the median ner\'e (sej'aratcd from it 

, by the deep head of the ]>rouator teres) and four of the muscles 

ti»iiig from the internal condyle (pronator teres, flexor carjii railialis, 

aris longus, flexor stibltmis digitornni). It lies tiivt upon the 

nnion of the bmchialis iinticns, then U[iou the flexor jirofun- 

> digitoruni, lieing there bound tlottij by a pnwes-s of deep fascia, 

ii* joined in the mi<tdle of the fore-ariii by the uVtiaT iyctvc, 




THE FRONT OF THE FOKK-AKM. 



where it reacbes tht; lionler of tlie tlexoi- ciirjii iilnaris, wliich lies 
to ill- ulnar siiii: for the ri'st of its course. In the lower thiirl botb 
iirtfiT mill nerve lie compiiRitivply superKiinlly lietwei-n the tenJoni« 
nf tW flexor airpi ulnuris luirl the tlexnr miVlimi.'^, and they both 
1*81 fin thi! He.v.(ir profnudurt digitunim until they piL*» forwurd 
to the hand botwcen the annular ligament and a jirocess from llie 
tendiiii ol' the liexor earpi ulnarin. Two venre tomitta arc in close 
rolalinn with the artery. 

Surgery.— The tilnar aitery ix easily reached in its lower j)art 
liy an iiicisiun two inchea long ujion the outer ed^e of the tendon of 
the liexor carpi uliiaris. The tendon being drawn a littlu inwanln, 
it would only lie neiessury to divide the intei muscular hiyer of the 
deep (n^Liii in onler to expoxe the vet<.-iel with tlie nerve on its ulnar 
side. The opemtion fur tyinj^ the artery in its upper part between 
the iiexor niUfde.i is impracticable on the living body, but the veBsel 
may be rtarhed on the t^ubject by seiHiRiling the liexor car|)i iilnaris 
lr<iui the tlexfir .>-ubliini9 digitorum until the idiiar nerve in exposed, 
when llie lulery will be found Ut its outer dde. 

When the ulnar artery is tied, the circulation is mainly carried on 
by the r.idial through the imlinar arches, and also by the anterior 
and ]iostertor iuterosseoiis arteries, which uuaatomose at the back 
the birc-arm. 



^ 



Branches. — 1. The Aiitrrinr iilmir nrKn'rai (Fig. 21, lo) will be 
found between the bi-aehialis anticus and jironator tfita, running 
u|i in front of the elUiw joint to join the anterior bruBches of the 
aniistoniotic, and inferior prol'untia. 

2. The I'liKtirinr iilviir rft-tirrenl (i2) is to be followed beiieatli 
the tiexor suldiniis and flexor caqii ulnaris to the back of the 
internal condyle, wliero, alter pissing l>etween the heads of the 
Hexor cjirpi ulnaris, it runs in the groove occupied by the ulnar 
nerve, and ana-stonioses with the inferior profumla aiul ana-stoinot 
arteries. 

'A. The JiilrriMseniit arUrij (i8) is u short trunk arising about 01 
inch from the conimencenu-nt of the artery. It is directed Iw 
wnnls to the interosseous sjiace, where it .subdivides into anteriot^ 
and posttrior intenisseons branches. 

The potlrriiir iiilfrotKoim {msses between the ttidius and \ilna in 
the interval between the obliiiue and interosseous ligaments to join 
the [xwterior interosseous nerve at the l>ack of the fore-anu, whi 
it will be dis.sected. 

The (Ulterior iiitrrnnsuoii* (2o) is to be followed down the front 
the inten^sseous membrane, where it will be found lying with 
branch of the median nerve between the tiexor longus pojlicis 



nar 
iti^_ 

i 

lor I 



k 



THE ULNAR NERVE. 



59 



flexor profundus dijjitorum, until it disappear< bencutli the pnmator 
t]Uiiidnitui> to i-eiich the wrist. It gives otf numerous miucuhir 
branchex ; a meilian branch to iu:com|inuy the median iien'e (ponie- 
timee of large size) ; two iiiilrient arteries to the radius and ulna, 
which urv directeil ttnrardt the elbow ; and n commujiiattiny branch 
U) join tlie anterior eari)al arch. 

4. The anterior Cardial arterij runs beneath the finger tendons 
ne»r tlie lower border of the pronator (juadralus, to ssupply the 
Iront and back of the airpu». It anaslomascB with the anterior 
I'MTpal from the radial, twigs frmu ttie ant-erior Inti'roswouB, and 
h'C.urrtnt brnnrhes of the deep palmar arch. The ponterior carpal 
artfry pa.«se8 to the back of the wrist, and will l>e Seen later. 

The Median Nerve (Figs. 20 and 22, see also p. 34) after 
|>awing between the heads of the prc^nator ICR's, and Wtween the 
RuUal and ulnar origins of the flexor subliinis digilonim, crosseai 
the ulnar artery to lie between the Hexor sublimit and flexor pio- 
(ondu^ muscleij. Ne.ir the wrist it is placetl superficially !>etvveen 
llie tendon of the flexor carpi radialin and radial Nide of the 
fteior iubliniijs, and psisses lieneath the niniular ligamcut into the 
band. 

Branches. — The tnedian ner\'e supplies all the muscles of the^;^ 
front of the fore-arm except the Hexor carpi uliiaria and half the' 
lleior jiroftindus. As soon as it enters the fore-arm it gives 
liraucbes to the pronator teres, Hexor caq)i radialis, flexor sublimis 
iligilorum. and palniaris longus, and, aft^T crossing the ulnar artery, 
pve» otf the antrrior inleromroxu nerve (Fig. 22, 25). This passes 
duim the front of the interosseous membrane, giving branches 
to the Hexor longus polliiis and the outer half of the flexor pro- 
fundus iligitoruiu, and the pronator tjuadratus, finally reaching 
the fpint of the wrist-joint, where it gives a branch to the 
uticulation. 

A riitanroiu palmar branch of the median (Fig. 20, 30) arisea a 
diort distance alnive the annular ligament, over which it passes tu 
Ik: di-tributwl to the skin of the [lalm. 

Surgery. — The median nerve is often implicated in wounds above 
llie WTJst. It nuiy be fmind there between the flexor carjii ['adialis 
and the flexor sublimis digitnrum. 



.f ' 



The Ulnar Nerve (Fig. 22, 2) enters the fore-arm behind the 
internal coinlyle, by passing between the heads of the Hexor carpi 
ulnuu. It lies under cover of tliat muscle and upon the flexor 
profundus digitorum for the whole of its course in the fore-arm ; 




fiO 



THE FRONT UK THE FORE-ARM. 



lUiil about the middle third of Ihc fore-arm comes into close tt-latio 
with thi! ulnar artery, hikI, kct'iiinj; to its ulnar aide, Bccompanie 
it uver thf unnuliir ligauieiit into the imlni. 

Branches (Fig. 22). — Tlie ulnar iktvl- gives small nrlieukr 

lininthen to the bai'k of thf 
elbow, luid supjilies one and n 
!mir ol' the iiiusi-li'.-' of tbi' 
t'lirt'arni, \i/.., tin- ticxor carjii 
ulnaris iiud tlie inner half of 
tliL' lli'Xur firtifundus liigitoriuii. 

In (In- lower third of the forc- 
anii the nerve j-ivcs a dorml 
hninrh (20), which turns back- 




Tig. 22.— Hep]) JiMertioii of tlie front 
rif tti« lui-e.nrrii nnd liiind (froia 
I]ir» hfvlil nnJ LpvriUc). 



1. Sui.i 
•J, 2. V 



liinr nerve. 




}trni'lii:ilis lUiticun. 

Hiccjis. 

^[uM;ulo-spiniI ner^c 

Mt'iliitri nervi'. 

PuHti-rior intenwwpou* tiiTvc. 

I'ldimtor tei-es imd rtcxor 
radialia (cut). 

ExtonKor curpi mdiuli^ Inngior 
(cut). 
1(1. liiacUial artery. 
II. Supiimtor breviii. 
I'J. Flixiir »ublimi« diiritoruiii (I'Ut). 
la, 13. Itiidiiil niTrc. 
U, It. Fli'xoriarpi ulnariii. 
1 *). Kxlt'iiM>r carpi mdiuliis brcvior. 
Uj. I'ltirtr iirtor)-. 
ir. JUdiiil ori)rin of tiexur >ul>limi* 

digitorum (cut). 
18. Flexor profundui difriloruni. 
Ifl. Temi'in of nronntor tvrvn. 
■JO, 2U. l)or«al liniucli of ulnar nrrve. 
•il, 21. Radiol artery. 
'22, i'l. Deep brani'li of ulnar nerve. 
'iS. Flexor lonifun jHillicis. 
'J4. .Vlidui'tor niitilmi dieiti. 
i'j. .Vuteiior iiitcrosH-ouj* ncn'e. 
-6. ni^'itid bnuu-hei* of ulnar ner>'e. 

27. Tvudiin of Mtpinntor lonKiM. 

28. ihiv of tbc liinibnt'ale*. 

29. l'ix>ntitiir ■lUadratuM. 
31. Trndnn uf tiexor ciirpi nidialU. 
33. Ditrttnl branches of niediun ncrvr. 
•'t5. Addurtor Imnarrnuo i>allirii. 



J 



THE BACK OF THE FORK-ABM. 



(il 



•""intienenth the tenilon of tin- lli-xor carpi ulnaris to W distribuffil 
to tlic Wk of the little and hulf the ring finger n-s far as the niiilille • 
of tlicir eeciind plmlanges, iiml stuuetiiiieR ru])lacc8 the adjoining 
bnui-h of the fHdinl. 
Arutniirmu yaliniir branch of siiiidl cize ari«e» lielow tlii; iniJdh- 
ftt the forc-urm, and, nfttr rHnniri<< down in fnmt of the ithmr 
|jrter)\ liccoiut* cutaneous close ahovu the imniiliir lif^niiient, nnd 
I ili»tributed to the nkin uf the ]ialni on tlib uhiiir Hide, uonuiiuni- 
ling witli tlie pnlniar cutaneous* of the inediiui. 

' Bargery. — Tiie ulnar nerve is not uiifrei|uentiv woundcil or 

lfv)de<l ju«t ulxive oral the wrist, and must be sought lor entire, either 

Vtween the tendons of the llexnr carpi iilnaiis and Hexor dij;it<inuii 

■ublitnis, or in llie fibrous cjiniil formeil between the anterior annuhif 

nt and the process given to the hitter by the liexor carpi 

> >ne uf tlie most essential points in excision of the elUjw-joint is 
111 avoid injury to the ulniir nerve where it lies behind the internid 
coudvli'. 

The Badial Nerve (Fig. 2i, 13) is seen to arise from tlie 
nntsculo-sjiiral ner^•c opposite the elbow. It lies at first tijion tlte 
•u]>inator brevis, to the outer aide of, and at some little distance 
Ippdi, the radial artery; but in the iniddle third of the fore-nrm it 
l« in close relation with the artery on the pronator tere.-t, and occ4i- 
•i'luolly touches it, leaving the vessel at the lower third to cro.»8 
eoth the tendon of the supinator longus to the back of the fore- 
. and hand. 

The FoBterior Interosseous Tferve (Fig. 22, 7) arises with 

he railial and to its outer siile. It runs for a short distance upon 

"•Upinator brevis, and tlieii )iierics the muscle to wind in iU> 

Dl*l&nce around the outer siile of the radius. It will be seen 

am at the bnck of the fore-arui. 



The B.vck ok thk Fokb-aru, 

iTbe front of the fore-anii tuiving liceii dissected, the skin cjin 1* 
iecte^l from the back of il witlmiit I'urtiier incisions, but an iuiisiun 
injrt be made along tlie inner border of the hand nnd across the 
Duckies, to permit the reflexion of tlie skin from the Iwck of tlie 
and. An incision is also to be made along the ihunib ami each of 
fingers, uud the skin retlected, and tlien the cutaneous nerves and 
■U, but e«J>ecially the veins, are to l)e dissected out of the gupcr- 
iWia.] 

Cut&neous Nerves (Fig. 23). — The back of the foTe-nim w 



C,-2 



THE BACK OF THE FORE-AJIM. 



/ nervfl 



»up])Iip(l in llie niiJdk' liy llii' limncheit of the mturido-tfiiml 
(2), which W!L» rtecn nbovo the eomlyk's of the hnmcnw in the 
<lin.MtM'tion of the back of the urm (p. 44), mid on the outer side of 
the. liml) hy brandies from the iinueiiln-dUnuruiui nerve (4), and 011 
the inner side by hmndiM of the iiitfnuil culaneouji nerve (3). At 
the wrist, on the outer «ide, the lar^e rtvIM nerve (6) pierces the 

deep f(i.scia in tlic lower third of 
the fore-iinu, and, after coinmuni- 
cutinj,' with the niuscnlo-cutaiieous 
nerve, diKtributes di},'iUtl hniiiches 
til Ixjth hide? id' the thumb, Ibre- 
fniger, atrd middle linger, and to 
the niiliid side of the ring linger; 
formiiij^ in addition a loop across 
the l)uck of the Imml with the 
iliiratl Itrtiiiih nf Ihr nlmir tirrrr [•] ) 
which apjH-ai-s on tlie inner side of 
the wrist, at a point coiTespondinj; 
to the lower end of the ulna, atid 
f,dve» digital liranches to lioth sides 
of the little linger and the ulnar 
side of the ring linger, joining the 
radial nerve across the hack of the 
liani!. The distribution of these 
<lorsftl digital nerves us\uilly does 
not extend ln-ynnd the niiilille of 
the second )ihatanges, the distal 
I>ortion of the dorsal integument 
receiving its supply from the palmar 
digital nerves. 

The Superficial Veins (Fig. 
23) across the back of the nieta- 




Fig. 23. — Superficial diinectian of the 
b«i'k of the fniv-nrm (from Uinoh- 
ft'ld Mini Leveillc). 

1. I'listerior limmli of intoi-n»l rut«- 

neoiij* iKTvc. 
'J. Kslernal rijtiinrou* branch of mus- 

Oulo-fpil»l lliTVC. 

3, 3. Inlemiil cutniifoiiii ncrro. 

i. Itndinl rein anil vxterunl cutanooui 

iipnc 
.5. r<i«t<Tior ulimr vein. 

lindiul nerve. 

Ilursjil Iji-oach of ulnnr nerrc. 



d 



SUPINATfin nATHI LOKOITS. 



«.;:{ 



"jiun, oMKlnuU' in an irrrguiiir imii, liDtii which utUk the nuliul 
lk<l pdxli-iior ulnar vcinx at itK innrr und outer vxtrvmitio) ; tlinu: 
Hixl rwuiid thf foi\--arm to join th«! rucliiil uml ulnar vein* rv-|.. . 
ci-ly, ttwl one or two hriuuhi'* lonn roniniuniciitionii hrtwci-ii li 
tuToe» the back of the foiv-*rni. 

[The ikrp fftficia ii> to Ik; rciiiuvirJ from tlif liack of thr fore-un 
aii>1 Imml, with tln^ exception of n l>un<l uhout an inch wiile, wbicli ij 
hi' left opiKMite the lower end of the ^Rlliu^ to form iIm 
iHii/rir li<iitiiuul {t"nt. H. 15). Thf^ "li'mler poHti'rior 1 
ery to the outer tmleof the extenxor I'Arjii uln«ri» i» to In |..c-. 1 ...i. 
.will l>e founil to Iw iin|>oii»ilile to remove tlie fa- ia eutiirly near 
nc elbow, wlier<.' it is ini-.orporateil with tim inii9>-.le».J 

Muaolea of the Back of th« Fore^arm (Fix. 24). — Thu 

blv-Hnn mu^c.lii arising from and above liiu external condyle of thu 

nmertU) ATv cither txtcn$iiTt or tiijiiniitort, and will Imi found in the 

lluwing oixler, lH-',:inning from the radial »ide ; — I, nupinator 

aga» ; 2, ext4.'n"or car|<i ludialis longior ; 3, extemior carpi rndialiH 

ior; i, exti'Uxor commnniM ilij^iti'irum ; 0, cxteiiNor minimi 

;iti ! 0, exteMBor carpi ulnaris ; and 7, ancoiieiut (coveretl !iy 

ci.i [•rolon^i-d from the tric4.'])«) ; another niliscle, the nupinulor 

rvi», lies under cover of the long muxclen and will >»e seen later. 

rtivili); ileeply from the lionei of the fine-arm, will he found four 

|lort exlenfor iuumIos, which hohlthe following position in relation 

one another from the rmlial .side: — 1, cxU-wior iMxix meiacdrpi 
aUicis ; i, extciiHor primi interniHlii |xillioifi ; 3, nxtvn»i>r iiieuuudi 
ktrmmUi pollicis ; 4, extensor iiidieii>. 

The muaclea arising front the hunieniit have ailditiunal origins 
om the fascia uf the arm or f^>lu intormiisciilar septa derive<l 
oni it ; oiiil two, vir.., the uxteiuor carpi itbiaris and enpiiuitor 

bvIk, have luldilionul orif^in" from the ulna. 

The Supinator Radii Iiongua Kig. 84. 4) is a long muscle, 
nd hwi been alnawiy seen in great jiart in prcvion* iliwi^ctions of 
br bend of the elbow and fonvarm. It (in*-* from the uppei 
ro-lhinlit of the ext^-rnnl hupia-comlylar ridi,'c of the humerux, and 
titn tlie external inli'rmuwular Mptum of the aim, wliiih eepiu-aten 

frntn the triceps ; and is iiitrrtnl into the outer surface of the 

l»w«r extremity of the radius at the bottom of the grooves for tlie 

xt>'uwn« oeiis mctaairpi and primi iulernodii {Millicist, rearJiing 

tiurly a ridge-like tulicrcle aliout u thinl of nn inch above the 

f*f the styloid procesK of tlie radius. Its tendon is cioiuml by 

I sliort ext'-nMirs of the thumb at the annular ligament, and tlie 

\d\»l U'.Tve pa><st>« l>eneath it t^i rciich the back of the hand, ll \* 



6* 



THE BACK OF THE FORE- ARM. 



mppluil by a special branch of the iiiuaculo-spinil nerve. 

i* a powerful flexor of the fore-ami, ami iiiny also bring the nu 

into a position midway between pifinBtioi 
Fig. 'U. anil supination. 

The Bxtensor Carpi Radialis Iiongior^ 
(Fij;. ii, 5, Fig. i!5, 3) iirtfu fi<iiii the lower 
thiiil iif the extemiil su]iia-c(in(lyliii ridge 
(Uiil from tlie external iiiti-rniuscnlar septum : 
iU tendon piisseji Ix-neath the cxlensoi's of the 
nietacaqml bone and first pliuitinx of ihethnnib 
and thmvij^h the second division of the annular 
li);nment, and haviiij.; then l>een cro-'i'cd by the 
tendon nl' the thlnl extensor of Iht- tliunib, i>^| 




iiiHTtril into the linsc of the nu'tnciir]>(il Ijo; 
of the fore-tinper (£ud nieUcarpal Ihiiu-). The 
nniwde aids the supinator longus in flexion 
of the forc-ariu, ami in an extensor and a 
ductiir of thii hand at tlie railio-cnrjial nni 
intercaqial joints. 

The Sxtensor Carpi Hadialis Brevior 
(Fi^. 24, 6). wliich is jiartly covered l)y tl>e 
long exttiis<'r, unVd fnini the outer con- 
dyle of the hnuients ; from the externa) 
Inti-rnl lipiment ; from the fascia of the 
fore-anjt. nii<l finm the intermuscular septum 
i>et\veen it aitrl tlo- extensor conuoinnsdigllri- 
rum. Its tendon [uusses, with lluit of the long 
extensor, beneath the two extensors of the 
thumb and through the second division of 
llic nuiiulur ligament ; an<l lastly beueatb 
tlie third extensor of the thumb, lobe innrrinl 
into the styloid process on the liase of the 



nil ^ 



ilig. 24. — Superficial nitucUt of the tmck of thr fiin'-iirin Jroni Wilion). 



1. Ricpm. 

2. Urai'hinlu untiiut. 

'•i. Lover purt of the trirepa, inierted 
into the olecranon. 

1. Supinntnr loneuf. 

.0. Kxlcn.ior larpi nulialii lonf(<<>r. 

(1. Exienwr cnrj)! rnilinlia tireviur. 

7. Tendons of iiiHTtion of lhe*r two 
muwlc*. 

.s. Extinsor comniunis tlii;itoruiii. 

ti. Ext<'ii«or minimi dipti. 
in. Kxicnwr rcrpi ulniiru. 
11. Anroneun. 



12. Flexor r«r]ii nlnarif. 

13. KxtciiMr OMii> nu'tacarpi nnd ex- 

tenaor priiiii inlemoilii |>oUici* 
Iriiig toother. 

14. ExtenMir aeciindi inteniodii pol- 

liciii. 

15. Po»lcrior nnnuhir liponpiit. Tlio 

lendoni of the rumiuciD extrniHii 
are seen on IH" luiik uf thr 
hund, and tite inudt- of initor- 
tion on the dortuni of tlir 
fingers. 



EXTENSOR CARPI ULNARIS. 



melacaqxil bone of the tiiiildlf linger (3nl metacarpal boiie). 
It u an eitt«n<inr iiiiil u etiglit ulHliioUir of U>e lumiL 

Thr Extensor Communis Digltorum (Vig. H, 8) arita from 
the rxu-iii.'tl oumlyle with the jiivruiliiig niiuclci ; (torn tho fiwcia 
of t.h« foruunn, «nil fr>>iii tlif iiil4<tiiiU4i:ilIar h(i[iU on i.-mth t>iil<« of 
ii. It ends in llirt-e li-ndoiix, whicL {hiih ihrutii^li tin- fuiirth ilivi^ioa 
of the iiuniilur li;;amcut with iht* exlvutiuriiulicii, uu>l, the inuc-nuiiil 
havin;; imWiviJeil, tbi- four teii<lou« thus formed ure iiutrldl into 
thi- fiti;/fr< in thr folhiwiii;; way : — Opposit*! the ini-tucnrpo- 
]'■ . t«^n<lon ivivivcn iili]» on Ijotli sides frvnn th 

in: , ' u]>i>n till' phidaiiT, and ii4 joined on thi' radii 

(iUe by till) t<'iKlon of the luuibrii'iiliH, linitUy its Inlvrul portion 
art) prulongetl to the hatm of the ihinl phuluiix, whilst the uiiddlf 
{Mntion is uttAched to that of the necond phalanx. The diviniu 
inUi thn-e ulipii (igu^^d on diajj;mm9 ia somewhat artifieiul, and inurt^ 
tie mode witli the ficu])M:l, since thc^ three part* ani, in the natural 
State, nniteti. The tendon of tlie cxlnuuir iiulifit joins the ulnar 
side of the flrxt or outrrnuMt tendon njiiHnitu thi> tirxt plialnnx ; 
thfl tiuidon to the rin^ lin^'er \» joined l>y obliiiuu teudtnuun Hlipo to 
Um teiulon.n uu each vide ; and the t^iudon to the little filler in 
Joineii by the two divinionn of the extensor minimi di;fili, both 
above and behiw llie Ixiiiii uuiliu}{ it with the tendon ul' the rtn|{ 

Tilt! nelum of Uiiii miiscle in Ut extend the wri«t and tinmen', amll 
in a very i^niall de^n-e the ellmw. It« prini'.i|>Al action, howovnr, 
is afWD the pniximul phalttiige8 (into which it ih nut directly in- 
sorted) ; llw true exteiiifon of tlie middle and un},'ual phulnng 
b<iin}{ the inli<rosi<ei uud lumbriculeK. 

The Extensor Minimi Siglti ( Kig. 24, 9) iui|{ht be taken lui 
a port of the coiiiiuon extenwr, but it ia leituruted from it by nn 
intrnnuMMiUr Beptuiii. It ariMt from the external condyle ; from 
the liinciH and fmiu the intermuMubir «eptu on each «ide ; and its 
tendon, ,'iftfr p:i-.iiii;; thMii'.-li tlie tiftli division of the annular 
Ii t^ and the iiliin, and over 

111. ^ i ril, in f^eiiendly diviiled, 

both ulilM liring iiintrtid into the coiuiuou expaiiitiuii on the lint 
phalanx of the little tinker, but the innermost reaching further 
forwanl than it* fellow (Fig. ii.', 19). This muscle given iodejicn- 
dent cxtcnMon to the little linger, chiefly at tito rnctaoarjio pludangeal 
joint, and aid« Ute cxl<>nHor coiuinuni!* in other re»(H'ctf<. 

The SSxtensor Carpi TJlnaria (Kig. 24, to) iii-urn from the 
lioc.k of the ejcleriml condyle, (roiii the fiutcia, and from the inler- 
tuoacular *cpta on cuiJj »ide; aud haa an additiunal uxig\,n Itouv uu 



66 



THE BACK OF THE FORE-ARM. 



expuDKion attached to the outer .side of the posterior boixlcr of the 
ulna, the fibres covering, but not beiu)! attached to, the iiiner 
part of the posterior surface of the Ixmo, TJie tendon juasca 
through the sixth division of tlie annukr li},'ament, and in a groove 
behind tlie styloid process of the ulna, to lie inserled into the bast 
of the iuetaeaq)al bone of the little tinker ( 5th nietMcarj)al bone), 
It JB an extensor a:id adductor of the hand, u feeble extensor of 
the fore-arm, and extends the carpo-inetacarpal joint of the little 
finger. 

It should be noU'd that all the flexorn and extensors of the fiirptu 
are inserled, diii'i'lly or indirectly, into the inrtacaryw!, and act upon 
the rndio-caqial, iiitercarjial, and carpi>-nietaci\i-jial arliculatinn* 
The extentori of Iht Jitiyrrt act most powerfully on the proximal 
phalang^es, the two other pliahinges being principally extmiled by 
the lumbricales and interossei ; the radiiil ejieiitori are olso alxluctors, 
and the iihinr rj-tennor is an adductor of the radio-caryial articulation, 
and the e-rltiinor cafjii radialia longior as-sist-s the 6Uj)inator longus a* 
a flexor of the fore-arni, the rest being feeble exteii.-ors of the elbow. 
The extensor carpi radialis longior is mijiiilird by the niusculo-spir.il 
ner^'e ; all the othere by the posterior interosseous nerve, u branch 
of the niusculo-spiral. 

The Anconeus (Fig. 24, ii. Fig. 25, 4) is a sniuU trtongnlar 
muscle on the back of the elliow, which is apparently con- 
tinuous with the tiicL'ps, but i.s separated from it by a narrow 
cellular interval. It is covered by an exjiansion from the temhiti 
of t]>e triceps, which must lie removed to exjioce it. It <in'*'« from 
the back of the e.\tenial condyle of the hiunenis by a seiainile 
origin, and spreads out to its tleshy imttrlion into the trinngulni 
surface upon the outer side (if the olecnuion and posteiior surface 
of Uie ulnn above the superior obliipie line. It is an extensor of 
the fore-anil, and is mijijjlud by a branch of the nuisculo-^pinil 
nerve, which pierces its ui)])er margin nn<i is acconi]<anied by a 
branch of the sujierior profuuila artery. lU deep surface is in illa- 
tion with the posteiior iiitero.sseous recurrent vessels and with the 
capsule of the elliow and superior radiivulnar joints (hence, when 
there is synovial effusion the muscle appears unduly prominent). 

[The long extensoi's miii-t \»- divided about tlie middle and lurni-d 
aside in oi'der to see the deep mufcles thoroughly, but the supiuutnT 
longus should be left uncut. The supinatoi' brevia will reiiuire 
careful dissection beneath the origins of the other muscles, an<l the 
arm must be fully pionated in order to stretch the fibres whibt 
l>eing cleaned. The ])Oflierior intero.«8eou8 nerve piercing the muscle 
is to be carefully presen-ed, and its btanchea tvattd lo live extenaorv. 



EXTENSOR PRIMI INTEllNODII POLLICIS. 67 

Tbc Supinator Brevia (Fig- 2b, 9) is an oblitjuc. niu»cle, 

coroi'd It the upper part by a tendinous expanKion, from which 

nine of its fibres tiike their origin. It nrine* from llie external 

Uleal ligament of the elbow, n few fibres perhaji.'t reaching the 

Mlernnl ci>ndjle ; from the back of the orbicular ligfinieiit of the 

ndiiw ; from the Iriiuigular space beluw the lesser sigmoid cavity 

oftJie ulna, and from the adjacent part of the jiosteriur Rurfiice of 

tht biinc for » short distance. Its fjisciculi sweep spirally anmnd 

Uie nuliiLs, and are vurrted into tlie upper third <il that bone, 

ulending Id the inner margin of the neck, the outvr margin of 

tie bicipital tuberosity, the obli<iue line, and the corresponding 

ptrt« of the anterior, external, and posterior iLsjiecls of the Inme. It 

iipierceii by the posterior interosseous nerve (which supplus it), and 

tile posterior interosseous artery passes between it and the extensor 

ladf uietocorpi [lolliciH. It is a powerful supinator of the radius on 

Uie ulna. 

The Extensor Ossis Metacarpi Folliola (Fig. i'), 13) ia 

liie only one of the special cxtensoi-s nf the thumb which usually 

baa an urigin from t>oth bones of tlie kire-iinii. It (iriVf^ from the 

niiidle of the posterior surface of the radius fir abuut two inches, 

ibe origin reaching across tlie Ihjiic fioiii the intcnis.seous line to 

lie attachments of the supimtlnr brevis and ]iroii!itor teres ; from a 

cviresponding jMirtiun of tin- posterior surface of the interosseous 

l&embruie ; and from two iuclics of the middle of the outer side of 

the posterior surface of the ulna, between the attachments of the 

Kpinator brevis and anconeus above, and the extensor secundi 

iueinodii below. The muscle becomes sujicrticial between the 

txteoHin of the caqjus and fingers, and having crossed the extensor 

orpi radialis longior and brevior oblitjuely, and the insertion of the 

npinator longtis, it passes on the outer side of the styloid process 

of the radius, through the first divLiion of the aiiiiiihir ligament and 

WIT the radial artery, to be inncrUd into the l)ase of the metacarpid 

bone of the thumb (Isl metaciqial bone), sometimes sending a slip 

to the trapezium and the short muscles of the tliuml). 

Tlie Extensor Primi Internodii PoUlcio (Fig. 25, 15) iiristi 
bom the ba<'k of the radius iumiedirtlely below the extensor ossis 
OcUcoi^ii pollicis and clost' to the interosseous line, fur a space two 
Ueha long and half an inch wide ; also from the radial half of the 
lllterci8Be<jU8 membrane for a corresponding distance. Its tendon 
Us to the ulnar side of the tendon of the extensor of tbc metacarpal 
kone in its whole course, passing through the .stmie division of the 
nuulur ligament, and is ]irolonged to be iiinerlcd into the base of 
till- first phalanx of the thumb. 

V 4 



<8 



THE BACK OF THE FORE-AKM. 




The Extensor Becimdi Intemodii Follicis (Fi^. 35, 8) arittt 

from the niiilille of thf outer liiilf of the jiosterior surface of the ulna 
between the origins of the exteni«jr os.-'Im nietaciiri>i pollicis above, 
and the indicator 1>e1ow, and from the tilnnr half of the currespond- 

ing portion of the interceseoiu 
Fig. M. membrane. Its temlnn Ix'comes 

HHjH'i'Hciul just uIjovi- the annular 
ligunu'iit, tliroii^h which it passes 
very obliipielv in a Bepatute division 
(the third) ; then crnsEiiig the tcii- 
dnna of the liiti<; and i^lioil radial 
extensors and the radial artery, 
it runs along the ulnar side of the 
extensor prinii intemodii to lie 
inaertal into the bane of the ter- 
niiual phalanx of the thumb. It8 
tendon receive.s fibrous pnx'esses 
(analogous to those given off to 
the finger extensors by the iu- 
terosaei) fiom the abductor pol- 



I 




Fig. 25.— Deep miisK'Iec nf the buvk of tlui 
fore-urm (from Sappcy). 

1. Supinator longua. ^| 

2, 2. Tricepa. ^ 

3, 3, 3. Extensor carpi radialis loiigior. 

4. Ant-onc'us. 

6. Common tendon of cxtenM)r communii 
digitoruni, exteiiioi' muiimi digiti, 
and rxtentor rnrpi ulnaris. 

6. Flexor ciiri^i uintihii, Ciiniei] luide 

from flexor profundus iliRitnruni. 

7. 7, ". Extensor tarpi radiulis brevior 

8. Exti'n»or necundi mtcruodii poU'-" 
9 Supinntor Iirevis. 

10. Exli'ii'^nr indim 

11. Insorliou of proiinlor nidii tcre». 

12. I'osteriiir unnul<ir lijfament. 

13. Extenaor ohIi metucarpi |>ullicU. 

14. Inaerlion of extensor carpi ulnuis, J 

15. Extt'uwr primi intoniodii poUici*. ] 

16. Abductor minimi digiti. 

17. Abductor indicis. 

18. UiirHal intcro&oooiu of fourtli in- 
terspace. 

Expantiun of extensor rommunui 
digitorum and tendon of exten- 
sor indiris. 

Tendon of extensor minimi digiti 
nimul to blend «°ilh tendon of 
extensor communis dij^torum. 



10. 



20 




THE POSTEKIOn INTEUOS8EOU8 NEBVE. 



69 



lieu un the outcT aide nnd iIik lulductor obliquiu on the inner 
aiile. 

Tlie Bxtenaor Indiols (imlmitor) (Fiv;. 26, lo) nrUfn from th< 
{KwU-rior Hurfiite of tin; ulmi bilnw llic prtrtiliiix mumlt!, hikI «lij{htlj 
fruiu iht." iulciH.>*»»-inii( nienilinuu'. It» tciulon if ciivt-iv*! by tlm* 
uf the comnion extuiiMtr, and riuiuiti^ throiij{h tliu fourth divinioi 
of the luinular 1 i}^iiiuc-i)t with them. Joins the ulnar itidu of the 
tendon lo thf fure-tingnr. 

Aeiuiiit, — Tlic fuinitnr i>uvi tnrjacnrpi ftiillicii is not only iin rx- 
t4>naor and a)>durtur of the motArarpitl Wme of the tlitinih, Imt it. i« 
alio ^fif-rtir uiid alkUictor of thi< wri>tt, and by initma of it« ulnar 
fihrea a flight ■ujiiimtur nf llic forc-anu. The rxlentor primi iiitrr- 
nodii hoD giniilnr lu-tions upon the wriat, and extfndii the Uiiimb ut 
thi^ cjir[»»-«u-tiu'arfi«l and uii'taiarpo-jihnbingeal joints. The rsUiuur 
mfufuli iiitrrntHtii acts upon tin; curpo-inctJU'Jir[Mil , nii!likriiqM>[iliuliUi- 
^*1 anil int»Tiihalnn;{iud jointii I'in thr hittur cium- bi-iiig rninfoivi'd 
by tht* conlractioti of rh« two llirimr iriuxi'b'x wbidi xi'ud i*1ip<« tn it« 
tendon), ;iud iud>i ulmi in xnpiiiutkiu of ihu rsidiuH. 

It uiiHt be reuKMulicn-d thai tlic plaui.-n of tilt! angular nioveinenUi 
of the thumb ut tlie cnr)>o-uietacar|Hil juiutH an* ubliiiue in relation 
with thosr of the tinjjtTs. 

Tlir rjirimnr iiuiifit ttliil rjrUutoT minimi iliijUi an- ui'i'ewory to tile 
i:orre*]Hmiling t^nilotin of the nxtt-nDor contmuniai, ntid ft«-r\°e to give 
indcjK^iidfiit action to the two digitJi. 

Tho Poat«rior Interoaseooa Artery (Fig. S!7, 8) arUlng fnini 
tlie intwowieous, u br»ncli nf tin' ulnar artery, r«iii'li(vt tho Iwti-k of 
the fore-ami by piisHing livtwrvn the railiiiit and ulna almve the 
iuteroueoua iiK-mbnini', but lietuw tiie obliipie lixuiueul (p. S*^.!. It 
Mp|mm bfUvi-rn tlie supinator bri'vis and cxti-iisor oiusin nielacarpi 
|>oUici8, (iiving nmiu-nlaT brunclu-!- to the extennora and u rer.uTTnit 
ntiirulnr branch to ihr ellxiw-joiiit ; it in contiiiueil ilownwanU rlone 
to Uie extcniior carpi iilimn», lictwi'cn the sujierlicial and ilrcp 
tuuBi-lei, aiiil terniiiiatc* by joining; tli'' p<i»triiiir i'ar]«d arterioK and 
the terminal bnuich of the iinlrrmr iiilrrnMriiit^ iirlrrii {lo), which 
will lie found lo reach the buck of the fore-arm by piercing the 
li,t,.r.~ieou8 membriuie ininiediutely above the lower end of the 
The rrrurrmt (6) branch ninti beneath the anconeus to the 
I. nil 1 nnd bai'k part of the cUxiw, where it itmutomo^teA with the 
de»c4>nding articular branch of the »iii[M'rior pmfiinda an<l the nna*- 
tomotic ftrliiiy. 

The Posterior InterosseouB N'erve (Fig, 8U, 9) in one of the 
two terminal branches of the niunculo-spinil, wliii'h hae lieen 
already nxa lo divide ou the outer tiide uf the sjhicu in tnmt \>t 



70 



THK BACK OF THE FOHE-AHM. 



tbe elbow and iM'ucatU tlie supinator longua. It can now be troced' 
running obliquely in the fibres of the supinator brcvis around the 
outer side of the radius, and at its lower bonier break! iij* up into 
mnsculur branches and an articular branch to the wrist. The mui- 

euUtr branches supply the estcn- 
FiR- 26. g^,r carpi rmlialis brevier, extensor 

communis di^'ilfirum, extensor mi- 
nimi digiti, extensor eori)! ulnaris, 
the three special extensors of tlie 
thumb and the indicator ; and the 
supinator brevis is supplied by » 
branch or two as the nerve pus8i'» 
through it. The artiatlar brantk 
to the wrist is a continuation ol 
the nerve, and I'eaches the in-J 
teroaseous membrane between thi 
extensors of the first and secoii 
phalanges of the thumb ; passing 
Wneath the hitter muscle it runs toj 
the back of the carpus, beneal' 




Vig. 26.— Dinection of the musculi 
DKTve iind its bmnchc* (from 
fell! uud LeveilK-). 

1. Triceps. 

2. Bnicluulis nnticus. 

3. Siipiimtur loiiguH. 

4. Biceps. 

a. Muaculo-spirul nerve. 
tJ. MuK'ulo-cutaneous nerve. 
". Origin of extensor carpi nkdiali 

longior. 

8, 8. Itadial nerve. 

9. I'oiterior intero'aooiu nenre. 

10. I'ronntor milii teres. 

11. Orij^tn of extuuMir carpi radioll 

brcvior. 

12. Flexor car|ii radiali*. 
II). Anconeus. 

14. Tendon of unpiiintor lon^s, 

15. Supinator brt'vis. 

16. 16. Ti-ndon of cxtcnBor rarpl 

di>ilis longior. 
IT. Extensor comiuunU digitorum. 
18, 18. Tendon of exlcusor carpi 

dinlis brevior. I 

19, 1'J. Extensor aeeundi iutemodii pa 

Uoia. 

20, 20. Extenior ossig metacarpi polUeii 

21, 21. Kxtonwr primi intcmodii poUid 



THE BADIAL. AKTKRT. 



71 



le tendrmii of iho r)il«n»rir atiumunit iligitarum. Beneath llie 

tiiiliir )i};iuncui tt jwiMulft-jpui- 

^tuiiic tbickciiinj;; of iu ccji- ^Vt- V- 

eclive liKsiie khi-ath uiny hv 

ntnil. 

TUc KodiAl Artery at ibr 

«l (Fill, -i'l, iS).— After Uav- 

pg the front of thr lower end 

thu nuliiiD (i*. 'I'A), the nuliiil 

cry li<.*» agiiuiHt tho rxlrnml 

Ktvml tigumeul uf the wri^t- 

Diut, unil lit-nralli the pxteliMirx 

thi' nic-liuKir|ml bonn un<l 

lit of t.li« thumb. It 

tj IH ri\«>r the )iiu:k of 

b« i:«rpa«, li> \.\w intiTviil )«• 
artMA llui metacarpal buuc* of 



J'. 



■ of iho bMl:k of 111' 

liiiwn by 0. K. I. 



J'- 
fS- 
13. 

[4. 
A. 

*!- 



Intrrior profuniln. 
NiiiK'tioi ntofaitdjt, 
I 

-M 'I »»*T<>. 

A. 



7. I' 



[i<i*tcn<H hi- 

Of pMtCllMI 



K'D. |*ii>it-i i-'i uiiri'it^Hiu* artATy. 
|V. Ellnunr Muunili iiilerimdii pol- 

|0. \ I'urtprv. 

II. I 
j|2. }. ' 'trpi mtdttriiiit 

|4. Kihui'ui uiipi r.i<liiili< liiniiiir 
Uld vxleiimat curpl ruiiuiti* brt- 
Tior. 
Extnwar cnmmunU ili^tonim hiuI 

>xt«iuor iiiiliru. 
Exhsiuur fc-cunili intrrnadii i»>l- 

fi7. !'"-•■•'■""■ '•"TaI »rt«r)r. 

, IH. K 

J 19. 1 "ifni (U^ti. 

fao. M 

' 2i. A 




72 



THE BACK OF THE FORE-ABH. 



sor 0^1 



the thumb and forefinger, where it ia cTosscd by the extensor 
tlie second jjIkiIqiix of tlie tbuni1>, and JaBtly jiasifeg into the pnlin 
of tlie band Ijetweeii the two bends of the aMuctor indicia (first 



\ 



Fig. 28. 



V 



im 



<lor?ul interosseous muscle). It is accoini>anied here a« elsewhere ' 
venio o.miites. 

Tbe Branches (Fig. 27) of the radial orten- ;it the wrist ve 
coiniucnly vnrj-, but should be five In niuiiber. 

1. The I'oflfrior fwr/xi/ (17) i« a .Htiiall branch which runs tr 
vcrsely across the carpal buni«, beneath the tendons, to join 



fig. 28. — A aei-tian ibore the mirldlc nf the ri|;ht fore-vrm (altered tnm 
Ik'niud). 



1. Anterior interoMcout vosseU and 

nerve. 

2. Rndiul reiweU and nrrrc. 

3. I'nmator terei. 

4. Su|iinntnr lonfru'. 

6. FU'«or oiriii radinhK. 

6. Supinator iirevin. 

7. Flexor »ul>linii» dixitonim. 

8. £xten>on-« turpi rudialii longinr 

et brevior. 
8, Flexor carpi nlnarit. 



Kxtenaor owia metacjirpi polliti 
I'lnar ve«i-l> aud nrrve. 
Kxlensor communis dicitnruin. 
Fifxor prfifundti*^ di;ri1oruiii. 
KxtriiM)r c:trpi ulimris. 
Median nerve. 
Pocterior intoronteouB veaaeb nn 

nerve. 
Extenmr Kecundi intemodii |k 

licia. 




THE yb^EBIOR ANNULAR LIGAMENT. 73 

carpal brancli of the ulnar and fonn an arch. F mm this 

dorial inta-oueinig arteries, which run on the tliinl and 

tfcwl int«rosseou» niuscIcK, rt-ceivc thu com-sponding per- 

' Bterie.'t, and hifiirtate at thi- Wfb of tlii' lin^'crs tu form 

I ional dujital nrteriea. They aniwfonioHP at t}ie web and on 

u&e fingers with the dijjital branches of the superficial pahiinr 

The Mdamrpal (20) ui the first dorsal interosseous artery, and 
tWly re.=einbles the othent. It runs on the fH.-eond dorKii! inter- 
VMetsat niUMcle. 

X The TtoTtalit xndicit (22) is a «iliiilar bnuich, which runs along 
ibe radial »i<le of the nietAcar{ial bone of tin- index finger. This is 
frequently rejdaced by a large artery which runs along the nieta- 
f«p«l bone and diviiles into branches to the fnri'-Hnger and thumb, 
'fing in fact the rudialis indici<<, a branch of the radial in the 
|«lffl, arising ejirlicr than uhuuI. 
■J and 5. The DormUis jxillids (24) are two small arteries which 
! distributed on the metaciirpal bone of the thumb ; one is often 
nting. 

The I'oitfricr carpul bntneli 0/ llir Ulnar artery 'Kig. 27, 17) will 

I found apjx'aring K-neath the extensor raqii ulnariri, luid having 

uplcted the HRdi formed by the posterior eaqiul of tlir radial, it 

1 in a bninch to the ulnar side of the fifth nietiicarpul bone. 

Tlie Posterior Annular Ligament (Figs. 27, 2!)) is a thickened 

rtion of the deep fawiu of the fore-arm and hand : it is attnchcil 

llstlie ridges on the railing externally and posteriorly, ami to the 

Hbeifonn and jiisiforiu bones internally. It lias six sulKlivisions, 

l*hich .'thould be carefully examined and coiiijiared with the grooves 

lUielKiue.o. T\\K jirxt division eorn'.--poiids to the groove on the 

BUtfT side of the lower end of the lailius, and transmitit the ti-ndons 

^ extensor oasis nietacar[>i jiollicis anil extensor primi intemoiiii 

licis: the wo/o/ division corres]X)nds to the uutermoat groove on 

liick of the bone, and transuuts tlie tendons uf the long ainl 

•"'il mdial cxt<.ns<irs of the wrist : the Ihiifl itivisiou correspon<is to 

CueiuuTow deep obliijue giixive on the Uuk of the radius, and trans- 

l*"!* the tendon of the extensor secundi intemodii poUicis : the 

'■"ft diidsiou, corresjKjnding to the innermost broad groove on the 

lias, transmits the tendons of the extensor communis digitoruni 

|«iui of the extensor indicis : ihti fifth division corres])ond9 to a very 

M'Sht groove on the edge of the radius (or is placed between the 

Iwnes), and transmits the tendon of the cxt^-nsor minimi digiti : the 

division corresponds to the groove at the back of the styloid 

xiai of the ulna, and transmits the tendon uf the extensor caT\i\, 



74 



PALM OF THE HAJiU. 




ulnari». Thus live divisions correspond to grooves on the tadin* 
and one to tiiul nn tliu iiliKi. 

The dorsal interosseous muscles, four iu number, can 




I 



niotit convenientlv di.sHecled with tho.^e uf ttu: palm of the hanilj 
(jKiSe 80). 

Thk I'alm of the Hand. 

Surface-Marking. — Tlif ddicauy of tht- skin of the palm will 
depend very nun h n[iiiii ihf iirevicius (iciiipation nt' the individual. 
Ilia in every ciwe it will bi' rmiiid to present no hairs and to be 
ribbed by the row.-! of p:ipilla', upon which the orifices of the sweat- 
dneU con be Been wilh a magnifying gla.'<s. If decompositioii 



Fig. 'JS. — Section of wrint IhrouKh iinteri»r niul pmd'riur uDnulor Ugamenti 
carjiuf {from Uciilf). 



tiaaif 



1. Ulnar rmaek. 

2. nn«r ntTvc. 

3. Cniiut for IIcxoi-k Kubliinir and 

firariiniltu tligiturum and Hrxnr 
on g LI II poUicis, uid mcdiui 
nerve. 

4. Tcndnn of palmari* longUK on 

antiTior nnnulnr ngnmi'lit. 
6. Semiiunar bonu. 

6. 8henth for flvxor turpi mdialii. 

7. Kndial origin nf annular Hgunicnt 

8. SbCKth for cxt<*n«u>r ossix mvUi- 

eurpi and prinii inti-modii pol- 
lieiK. 
V. lUdiol TmeU. 



10. 




Outer part of po>t<-rior annular 
Itpimeut. 

11. Oa ningttum. 

12. 8he:il)i ofextentor wcundi inter-. 

nodii uolliciri. 

13. Seapboia. 
H. Shealh of extensor carpi radialiij 

lonsior and brevier, 
lo. Sheath of extensor commuiua i 
indicator, 

16. Semilunar. 

17. Unciform. 

18. 21. Cuneiform. 

Iti. Sheath ot extensor minimi digili.1 
20. Shealh of cxtenaor carpi ulnaria. 
22. Pisiform. 



THK PALMAR FASCIA. 



75 



mpidly, lli<! culiclc will prolwlily Iw iteUtchvtl in part, 
1^')len upon exiuiiining iU deep «uttiu.'c, ilrpn-MionA cotTi-i*[M.ituliiig 
|t>u the papilla, will bn round. A fulness on cacIi sidi- of tlit- [lalm 
■riiimpomUi U> the «i>ccinl niusclen of tlic thumb adiI littlu KngiT 
Brtipectively, and the tenii« "thi-unr" luid " hypothcnur " rminvncea 
bre sometimt'ti applieil to thciu. Thu jitilni prvHt-nln thrve curvi-d 
line«, the proxiiuul and dinlul uneii VK'ing cun'ed in op|>utiite direc- 
tions, whilst the middle runs olili({uely ucroiw the pulni to join 
Ithe proxiuiul line ut the outer side of the hand. Il will be found 
■HI dinKcetion Uint th<; ]>oint to which the aupcrliciul piilniar arch 
Benches, eorn%pi>ndH pretty nccuratclr with the centre of tiiin 
kiddle line, whilst the point of bifiireatiun of the <ligititl urterieo is 
■uidway Wlwecit the distal or anterior line ami the web of the 
Kngen (Fig. 32). 

■ [An im-i"ion in to bo nnulc down the middle of the palm to the 
■out* of ihe fingrift, where another ia to be <lmwn nri'<M» tiic whole 
nridth of the hnnd, ami the two tlapst of xkiii iiiu to U- diii>eeted up 
Bn<l turned in oppovitc ditvctionii. It will be- better for the leu 
kilv'Biiced student to pay little altfulion t<> tiie uuimpoitunt cutit- 
■ifouii iMilniar brunclieii of nerveit, und to carry the knile at once 
nroiign the lino granular fat of the pnlni down to thf ^-liHiviiing 
ftaltuur faiin niui unnulnr lignnient ; but it ithoitld l>e renieniberiMi 
Hiut three unijill palmar nervui have heen ain-aily wen, vi/., from tin- 
busculo-entaneous (p. 49), the niedjun (pp. '10 imd .M)), and the ulnar 
EpL 40). Thf fuHcia covering the tIlUl)cle^ of the thumb and little 
Huger 18 much tliiiiner than that in the enitie of the hand, and will 
■ln{Uire one for il« jirescrvutiuii. The skin may be at nnce n'tbrtrd 
B(<m over thi- outer side of the lianil, but upon the inner side a small 
■rnnxviTBe miiM'le (pnlmnriti brcvin) is to Ix- f4>und jtixt below the 
ftisifonu l>om-, und in to be preserved with the piece of skin iutu 
^bich it in inserted, butlv, the nkin tiiust ixf euefully tomoved 
■turn the thiunb und fingeix] 

I The palmar fasoias are complex structure* which may W 
Biutly»ed us follows (Fig, 30); 1, the nuliiititiij pilmnr /dm-ui to 
■rhich the tenn " jiulmar fu'iciu " is usually limited ; 2, the mu»euloT 
■mtiVt inventing closely the muscles of the thumb and little finger 
Bnd the inlvrossei, tliu tatter lying deeply beneath the tendons, vessels 
hnd nerves ; 3, the vaijtnal faacia, a delicate' tran»]Min'nl eonuectivc 
Kmuc^ sheath surrounding the ves^ls, nerves, tendon.s and lumbricales 
^etween thi' rmliating and muscular fiisciiu, to Isith of which it is 
Klosely ailherent (Fig. 31) ; 4, the/n.«rio of lli-rdij, a su|srHcial layer 
Ibr rather louse fibres, continuous with thu su]>erlicial digital fascia 
and with tlic dutwtl fuseia over the Wk of the hand, This ternii- 



PALii OF THE HAND. 

nates proximally on the palmar surface by a rallier abrupt itiaigin 
oppo&ite t}ie bases of the nietacari)al phalongca. It is known a1m> u 
the euptrficial tratuncrse ligament. 

The Radiating Palmar Fascia (Fig. 30} eonsisU of 

Fig. 30. 




portionf, cciitiiil or digitnl, thenar and hypothemir. Thi- .-entn 
trimignlur in shajx; and attached to tliL- aniiiihir ligauieiit by 
apex, is largely fonued by the expan.-iioii of the tendon of it 



Fig. 30.— The pulnuir fiwoiic (W. .4.). 



nypothcnur muM-ular fiuda. 

Palniiiri« loui;u(. 

Hn>otliBnur acgiuent of rndiating 

Uiat'ia. 
Thpuur sognicnt of nulinting 

taacm, 
Diritul itegnient of radiating 

fawia. 



(i. Thoniir muflculAT faM'ia, 

7. CutmuKius proct'M of raUiating^ 

fascia. ■" 

8. Devp tniiisrerce palmar Cucia, 

9. Terniiiiitl slip of digital acgmenl| 
10. Voginul Oiacin. 
12. FiMciii of Genly. 
14. Digital fascia. 



THE PAIJIIAKI8 BKEVLs. 



77 



I, but U ttill jirosent wbvD thi» lutucle i» wanting. 

^BUlly it «x|>aii<lH towiirib ihv ruut'* uf tht; lln^'ere, giving r.ff in 

c^unte dtrun^; tibnu from its nnlcriur surface tu the akin, rhicfly 

thu ]>aliuar fuMs. (.)ji[iuaitv the licuila of the iiietucurpal b(ino« it 

puts into four ]>art», am: for ench finger, eonnLrtvd to^jcthcr by ilcej) 

iMwvitrse librca. Jjich sr^'iiirtit is prolimged o\fr the iilifuth of 

|ji" conr8]«iniling flcxni triiibin, ond (iually diviilcn into two luu-ml 

KHils wliiiJi pnwi inii« oil i-illitr w«li' to Vk\ attflrlicil t."> tbc »hafl of 

hi' nn'tJti«ri>al phiiloiix, uu<l may In' jimlongi'il on to tli<' firnt iiitcr- 

lialnii};i'iil joint uiul niiildlc jiliuliuix. Tbv Inlirnl tlu-iwir and 

kypotheimr {tortiuuM uf tliv nuUatiiig fa«cia nre muck thinner tbui 



Fig. 31. 



-i 




be otutml j.ioitioii, uml nu'mly blend with the foMciii rovcring the 

Roxlet of tkf tbuiob nncl litlU' linger. 

The Palmai^s Brevis (Fij; IH, i6) i» ft hiiiuII luuix-le nuininjj 

RKwrvely below the ]iii)iforui liune and iniiiu'diiituly IxMieath the 

in. ArUimj from tbc inner c<l(p; of the t-enlral fu«.iii it crosmai 

liu ulunr artery and nerve, and i« inieiieil into the skin on thu inner 

of the hand. Il is lujijilUil by the ulnar nerve. During iUi 

Dntr.ictiou it |iiii;ker>i tin- *kiu nt iu iimertion, ini'.reu»ei< thu 



F|{. 31.— Tnuuvrnw •eetion of hwul iliowing jwlnwr faaoiu' (W. A.). 



raliniir tnlt'KuiiiKnt. 

F«L 

KadUtiDE rueU. 

VmkI* and oirve willi vitgiluU 

Is. K' ' I'imni'i'linx fhniu 

lodijitine >lru>itirr« 



Luiiibrirnlu with Itcxor tvniJoiu. 
Fujh'U iif inlrruMi^i. 



8. r«lniu* inti*ro)«('iMiii, 

U. Dunol lolirouiHiui. 

II), ytft«rar]ml l*ont*. 

II. K»t«i»or ti'iidaii. 

VI. iJoriol fiuola. 



7H 



PALM OF THE HAND. 



promiiieiifi- >>( the hypothenar eminence, and Blightly deep 
hollow of the liaiiil. 

[The iciitral jiurttiiti of thy pulinar fascia it lo he lU-tiichedi 
the otinular li>;auiint anii tuiiit'il ilr>wii, tare bring taken not tn 
injure the vessels auil neivi-s whidi art' close Ucniuith ; and thi'st- are 
then to be rk-aueil.] 

Tlie Superficial Palmar Arch (Fig. 19, 24) is the direct con- 
Fig. 32. 





tisaation of the ulniu- artery, which ivachea the pdni hy pa 
over the annular ligament on the radial siilc of the pisifonii hone 
and beneath u little libroiis Aiy> from the flexor caqii ulna 
(p. 57) : it then lies between the radiating palmar fascia and 



Fig. 32. — Bvliition of palmar arches to flexure lines of hand. 

1. Inforior fold. 6. Rndiul nrter}-. 

'J., Middle fold. ti. Supcrlirialu volic. 

3. Suptrior fold. 7. Itit-p |iiiluiararcli. 

4. Ulnar artery. 8. Supcrlicial jmlmar arch. 



THE ULNAR NERVK. 



19 



tcnilons aud nerves. Thu vvkvA i» nubjeut to v«ry groat vikri&tioDS, 
It if rvgiilar, fonux an tircb witit thu loiivi-xity r<ii°M'anlx, reachin); 
iilxmt lui'iwuy botwitn the aunuljir li^iuui-iit uiid the i-oot •>{ ibo 
liddlr tiiiger, a» far ii» ihv iniJiJiK of tin- thrve |>uluiar fiirruw* 
Tig. 2i). The arr.li iti ciimplRttvl on thr rmlijtl Me cillier Iiy 
bo «up<-rfli:ial volar liruiich of thn I'ailial urtr.ry, which (jriuitully 
(('r«;c6 » faw of the M>rvh of t)ie tili<lui:lor {iiiUic.ia, or ini>ru 
pniiDOuly liy the nuliali* imlii-iii (]). »H) or prinoi'[>« pollku : 
ftmvtiined by ull of ihi-w. From it<i couvoxity uri' yiveu off 
|>ur (hijital itrtrritt, the first of which ruiin to the ulnar siilc of 
be littli- liuKiT, whiUl thi- ihive otheni bifiiniite ulx>ut hidf un imh 
um the wcl) of till' fm({cT>< to nu|>|>ly ihf riidiul "iile of tlir littU- 
\l\\!.vx, U)tli Kidi'N of the rin^', Kith sidus of ihi'. iniddtr, iiml the 
Inar half of the indvx tin((er. Thoiw 1iruiirlii-'< tnicrd iilon^ the 
|Sde« of the di|{it« will l>o found to xniiply the <'Ululii'oiii* Ktructurea, 
be Kheathn of the tetidonx luid the joiiiij<, and M'tid twi;p« luiek to 
atomoTM* with the dor»at urterieii ; llually thi-y KU|i|dy the ]>iil)< 
' the t<-miinal ]ihidunx aud fonn u plexus beiu-ulh llie uail. Thry 
! accoin]>unied by the distal uer\'e8 ; but tlii'ir relative pnnilinn 
lifferM in the palm nnd in the fingi^m, — in the former the ortorie* 
MUjiertii'.inl, in the latti-r the nerves. 

Kach of the thn'e onti-r diK'ital iirt<^rie» at it), point of bifurcatiou 
ivcs a c-oinmunicatinK Iwi^ frotn the interi»wi'oiii« branchot of 
bo deep arch (radial artery), and an tntrrmflnntrpiil branch from the 
pifuruiliou of the durxid digital arterien. The braiich to the furc- 
IJger inowulaten with a brunch on the other Mde of tin- fing<?r 
dxrived fiom the radial (radialin Mulieis). 
The Profunda Artery >k a »niall communicating liriim-h arixin^* 
um the uln:ii' iin< ry iu< mkih iu it ha.'' croMud the annular li-jumviit. 
It pa&9e8 deeply, with the ilei-p bnuii'li of the ulnar iiorve, In'twoeli 
be abducU.>r and the flexor brevia luiniiui dij^iti, and alou^' the 
' kide of the titiciforiii ppK'ex.<. It will lie found to complete 
be deep palmar arch uf the ra<lial artery. 

The mixliaii artery from the anterior interoHMLNjiu (pw S9) i« 
CiinetimeAenlat^tKl and join] the >u[ierHcial (Kilniar arch or supjUiek 
Lgital biaiuhrs. 
The TTlnar Nerve (I'ig- -t, 2h) ncoompiuiie.t the ulnar artcrj- 
over the anniilur llxanuiit, lying tn iu ulnar sidis and i mined iately 
~|ivide» into a «iiperliiiul and a deep ]>oi-tion. The iletpj) /iriiiuA (22) 
L'.omjiunien the piofiitnla branch of the ulnar artery (7. v.) supply- 
R^ the niuiscle.1 of thu little linger, aud will be seen axaiu in the 
ecp dis-'ection of the ]>alm. The auperjicitit diintiim neiula n amall 
rig to the fulmaris brcvU and to the integiiinent of the uUuit 



82 



PALM OF THE HAM). 



turned (lowii, uti«l the flexor teiiJous witli tlie kiiiiltncoliw ma 
dcaiieil and traci-il to tlii-ir iiiserlious. The shualhs of the fleXO 
Ifiiddiis hiivi- Im-n nlwa<iy "le8<riln'd (j). .>4), but at least one mow 
."hotilil he laid njieii in ohIlt that the tendons may In; well seen.] ~ 




The Tendons of the Flexor Bublimis, U>m in nuiiiWr, [na 
)>(::neiilh tlie annular ligament uml lie iniini-diately tieiiealh thi 
braiichex of the median nerve in the jiahu. Kneh tendon become 
Homewhat Haltened, and on the first phiJunx splits into two ]>ortiona 
wliich give jia.«sage to the tendon of llie tievor jirofiuidus betwtel 



Pig. 34. — Diagrmm of nrjnl and diicitiil bursnl xhptithii of finger tradoaa. 



^ 



1. C'arjwl Afaoilh of 0pxor lon^ft 

IKiUicis. 
Car]"'' 'heath of flrxors subliiuis 

■nd profundtu. 
3. Digital iheath of flexor loiigUK 

polUoii. 



4. LiiH/n hfjialira. 

•5. Dicitiil ahrath of index finger. 

tl. rn<.viiiiul Itpxion fold. 

8. Middle tlrxioa fold. 

10. IJijtal flcNion fold. 

I'J. liiirltjd (.liciiUi of little fing«r. 



THE LIMBKICALES. 



89 



tifiu, iind, ttfttr iiiiiting benuilli the jiroliiiKliis, iliviile again to 

Wobk' inM-rte<l inl.i the riilgi'.s lioixlfi'iiig the jKiliimr Mtrfiiie of tlie 

j>baLiiix. Thu tendoiia nre itniti'd to the sbi-ntb atul ti) each 

bj- tlir«iul-Iike pnjcesses {liffauinilit lumjii), ami liy sliortt-r 

Iwnd-i {liijamnitii lirrvia), the hitler cuiiiicrtiiig iiuli tuinhiii 

*ilb the Irf'lil "f the phuluiix near its insfiliuii. 

The Tendons of the Flexor Profundus (Fij,'. :W, 7), nlwi 
fuur in nuiiilii-T, lii- lieiniith Ihf imrcsjHiruiiii^ KUjierlicial tendoiif, 
*lui)i they jK-rforate over thf first ]>halaii;;<'.-' ; tln'V then imss on t<i 
vtiiurrtrJ into the liu-tes of the tlitrd [ihulanges. 

Escli piir of tendons is in\i'>teil hy a digital bursal sheath, 
*hicli reaches aliont un inch above the elcft of the liiiK« i> ; that of 
ill" little finger usually eoitiKmnic;itiiig with the carjial >bealii already 
'Itscribeil (j>. 57). The digitid (<biMlb of the Hexor bilious jjullici-i 
i> neiirly always cnntinuous with tlie larjial aheath of tlie ten(hin 
'«aMth the annular ligament, a'.id the larpal sheath oicasioimlly 
Mnununicates with that i>f the linger tendons (Fig. :)4). 

The Iitunbricales i Fig. 36, 7) are I'onr little niii(<i-hf< connected 
»ilh the deep flexor tendons, unci bear smue reseuddante tit eartli 
*(>rm» (lumbricij. The first lumbriL'ali.s, eounting from llie rad iai side 
(nd tometinies the recond), uritit: fmni llo' niilial side of a j-ingb; 
ItnJnn, but the others nriisr: from the adjareut sides of two deep 
Itiiiioai. The four muscles end in sniidl tendons which wind to the 
8di»l sides of the four hngers, and. passing in front of the palmar 
''•STersc ligiunent of tlie nielaeuqius, jue iimrrtid into tlie exjKUi- 
NOMof the extensor tendons on the imck of the first phalangec. 
The lumbricides act with the interossei as Mexors of the lin-t 
jWuige* and extensors of the second and third ]ibalanges. The 
^1 and -ecoud art- mi /ijilinl by brani hes of the median nerve ; the 
iMrd mid fonilh rweive twigs from the deeji lnuneii of the ulnar 
^L«BTe, which will be seen in the deeper disseitioii. 
^P The Tendon of the Flexor Iiongus Pollicis (Fig. 36, 9} is 
I ^"11 the nfune level as the tendons of tlie flexor piofundiii, and can l>e 
'RK«i l)etween the sesiinioid bones and the two heads of the Hexor 
IflJVis ixdlici- to the liase of the terminiil jibuhinx of the thumb. 
'|j vaginal ligament is nuich b-ss strongly devebn»ed than those of 
llic flngerx. 

[The t*;ndons of the (lexor iirMfntidiis are to he divided (but not 
the dexor longus ]Kd!icis) and turned down wilh the lumbricales ; 
iJw miueles of thu little finger uml thmiili are lo !«■ carefully 
iJiiniTtf d ] 



O « 







i 



MUSCLES OF THE THUMB. 



iIUSCL£3 OF TBE LlTTLE FiNOER. 



^M Tlie Abduotor Minimi Bigiti (Fig. 3C, lo) is the most siijuit — 

^H licial and the iiiiKnii(i!<t of tlie.«e. It^rUrs frmn th e pis ifonn bon^ 

^H oiitl 

^H Mm 





oiitl slightly fpiiir tlie ti^iiilon of (he Hi-xor carpi uhiaris, and is iw— 
laifii into the ulnar side oFtHe Imse of the first phalanx, giving i 
BiiiBll tibroiiH I'.xiinnshtiiTilTE'e ulnar sidi' of thu extensor tendon 
opposite to the similar expansion derived from the thinl 
interosseous. 

The Flexor Brevis Minimi Bigiti (Fig. 36, 8) is often 
clos«.-ly coiiiiected with the aljiliietor ; but the -leep branches of the 
ulnar artery and ueiAe which pasn between the two will serve 
guides to the point of depuration. It on«f.< from the unciform pr 
cess of the uneifonn hone and from the nutnilar ligament, and : 
iiiterteil with the abductor into the iMise of the first phalanx. 

Adioiiis. — The abductor and llexor brevi.s are flexoi's and abducton 
of the first plialan.v, and the fomier by its slip to the exte 
tendon aids in the extennion of the second and third jikalangMi 
both muscles not secondarily as llexors of the metacarjial bone. 

The Opponens (tlexor ossLs metacarpi) Minimi Bigiti 
the dee]>est of the set, and nri-nes fmrn the lUicifoiin jirocess close I 
the jireceding muscle and from the annidar ligament. It spr 
into a triangular sha])e, and is illlltrt^■d into the inner margin of tb 
shaft of the fifth mctacarfwl bone, thus re:femb!ing the opponcn 
pollicis a.s lo in.sertion, but the power of " o]ipoaition " iu the 
little finger is much more limited than in the thumb. The uieta- 
caqud botu- of the little Roger, however, has a ninge of from 10 to 
l.'i degives of movement in the nntero-])08terior direction, and by 
means of tbi.- ]iower of flexion the transverse diameter of the hand 
con be diminished, and the hollow of the palm increased. It 
should Iw noticed that the base of the nietocariml phalaiuc of 
digit is somewhat saddle-shaped. 

Muscles of the Thumb. 

The Abductor Pollicis (Fig. 36, a) is a slender muscle, and i 
the most su]ierliciid of the series. It aritt* from the anuulnr lij 
nient, and ttsunlly from the ridge on the trapezium and from 
tul)ercle of the scajjhoid. It is rnnerlnl into the outer si«le of tH 
lane of the firet ]>hHbmx of the thumb, with the outer half of ill 
ilexur brevis, and gives n fibrous expansion to join the side of 
.on of the extensor secundi intemodii pollicis. The superficia 




THK Lt'MimiCALBS, 



SS 



tbcm, and, alu-r uniting tx-ix-ittli tli>- ]>rufimilii.->, ili\iilir ojfiuti \u 
Ixjirotiic itiwttiil inlo thi! riil;>rs IxiiilfrlnR thr ]iii1miii' ^lIrflu•^> {•{ tin- 
"ecoml phnlKnx. Tlic t«ii<1<>ii8 arc unitfil In ihi- xlimtli nml tn i-iu'li 
other by tlirvflil-likv pinriMcx (liQuinnitii /im</<i), aixl )>y ►ImrUr 
ploxtic liiiml- {lujiimiiitii liririii}, the hitliT ciililiirtilig I'lieh U'luloli 
with the I'roiil ut the ]>hiiliiiix near it" iiiM'ttiun. 

The Tendona of the Flexor Proftindus (Fij,'. 30, 7), hIwi 
four iu iiumbi-r, lir l>fiic«th Ihe forrrsiHmiliiiH <<ii|>LTru'iul tvudunv, 
wliich they jK-tfonili- ovi-r tin- tirnt iilmlnn^ji-H ; thi-y then pilau on Ut 
I* intrrtnl into tin- 1iiUi<:.M of the thinl idmhuijjes. 

Kttfh pair cf tun>Iun« is investeii liy u digital bursal sheath, 
which ix-achcn alKHit tin iiuh alHJVo the deft uf the lih^;ii' ; that c.l' 
the little liu^'cr usually I'oniniiinicalin^' with the ear|>ul iliealh alrcuily 
ileticribeil ip. 57). The digital hheiilh of the (lexwr liiiigus |><illici4 
is nearly «I\vuy> (onliniioui with the caqial *hi-<ith of the temloii 
bene^ith the annular li^ann-nt, anil the ear|ial sheath <h caitionalty 
lomniiinii-atex with that nf the tingiT tenil<>n>i (Kig. :J4). 

The Iiiunbricalea (Fi){. 'Mi, 7; arc four littlo inniteleM roniiectttl 
with the ilee]i llexor teiiilon*, and ln-ar winie r«'BemManee to earth 
Wunii" (himlirici '. The lirHt lunibrienlitt, eouiitin;; from the radial aide 
(and nometiiues the necuiid), iiritu from the nidial side of a tiiicle 
t«ndun. hut the otliet* iiriV from the adjacent sides of two ileep 
t«ulou». The four niUM'kt end in >niiill tenilons whirh wiml to the 
nttliul Mr* of till' four tinyers, and, jmsainy iu front of tlie [uilnnir 
ImnxveMM^ lil^anient of the nietaenrpii>', am imntnl into the ••x|>nn- 
«ion» of the extennur teniloliH on the Imek of the firxt |ihalaiii<e>-. 
The lumbricHleii act with the inleroiwei a» (lexorn of ihu lir>t 
phulau};eK and exten.turx of the (second iimt thini phahing\-x. The 
firet lujd weond are »ii/>/</iVi/ by bram her. of the inediiin nerve ; thi; 
tliirxl luid fourth receive twi;^ front the ileep linmch of the ninar 
nerve, whirh will be seen in the tleefier disseetion. 

The Tendon of the Flexor Iiongus Pollicis (Fig. 30, 9) i* 
00 the NUue 1e\el an the t^nilonn of tile lle.\or profundus, and can Iw 
traced l>etWe<'U the »et«»moid bolien and the two heHd>i of the llexor 
bivvis [Mjllicis to the base of the leruiiual phalanx of tlie thutiib. 
Its vaginal ligament in niiuh le--s r<trouj,dy develiiped than tho>e of 
the litigem. 

[Tlic tendons of the llexor umIuikIus an' to 1m< divided (but not 
the tiexor \iAv^\i>i pidlicii)) aii<l tinned ilown with the InnibricaleM ; 
the inU8vlu8 of the little linger ami thumb am to lie carefully 
tliatcctorl,] 



m 



i 




«G 



MUSCLES OF THE THUMU. 



its insertion, between which the tenilon of the long Brxor i* 
placed, one, the outer or suiH?rficifil heiid, being nion; or less ron- 
joine<l with the abdncU*, and the other deeply placed In'tween the 

adductor oblitjuu^ and the ah- 
'■''f- *• ductor indicis. The outer irrim 

from the lower part of the annu- 
lar ligament, and is inserted 
with the abiliictor into the outer 
side of the base of the first pha- 
lanx ; a Besamoid Immic being 
develope<l in its tendon. It is 
nsually joined by an obliijiie slip 
from the iiflductor obliijuns. The 
inner head, of verj- i^uiiill size, 
ari:<es frtiin the ulnar side of the 
l)U«c of the first nietniarj«il bone, 
and is inserted with the adduc- 
tor obHcimi*. It hiL* the aspect 
of a small j>almar interosseou* 
muscle (Fig. 3.')). 

T)ie Adductor Obliqutu 
Follicis (Fig. 3(i, 5), formerly 
known a.s the inner head of th.i 
flexor brevis pollicio, arises from 
the bases of the second ami thinl 
iiietacarjial bones, the sheath of the Mexnr carpi nulialis, and the 03 
ntagnum. It is inserted with Iho dee[i head of the Hexor b^evi^ 
lUid thi- ailductor tran.sven-us into the inner sidi' of the base of the 
first plialanx, a wsamnid bone beiny developed in its tendon 
where it plays over the bead of the nietacarjud bone. It often girts 
an oblique slip beneath the long Hexor tendon to join the outer head 




Fig. 36. -Husclea of tho himd (from Wi]M>n). 



1. Annulur lipiuirDt . 
'2, 2. Origin und insertion iif tlic 
abductor pollici« mumk'. 

3. Opponens poUicU. 

4. Superfii'iul portion of the flexor 

brevi* poIlii:i». 
6. Adductor oliliquiis poltiris. 

6. Adduol^ir tmnsvorsus pollir-b. 

7, 7. Thpluniljriialpsniuiiclt-g,ariainK 

from tlie deep flexor tendoim, 
upon which the fiirun-s urn 
Iilaccd. Tlio tendoiu of llie 



flexor sublimiii hare boon T»* 

moved. 
8. Flexor brevia minimi di?iti. 
'J. Tile trndun of the flexor longni 

ptdlicii*, passing; lietweeii the 

twu portionsof the flexor brvrij 

to the luHt pliulanx. 
10. Ahduitor niinuni digriti. 

12. Pisiform bone. 

13. First dorsal interoMeous inaieir, 

the abductor indiri«, 



DEEI' BRANCH oK TUK irLNAK NERVK. 



87 



I the flrxoT Iwvift, ajid wud» an t'XiHkniiioii to tbc iuner iiiile of tlie 
^tiTi>-. I U'luloii (u[ip<mite to the i(ini)ltiri?xiHmHi()ii 

BUI l^ Thi- ilfi'ji ]uiliimr urch i» burirtl in iu 

kvl uiigiti, nml i-iiii'rv>'a Ix-twcuii it ami the uiljttceDt bunler of 

luct4ir tniiisvcn.un (I''i|;. H.'i). 

The Adductor Transversus PoUioia (Ki«. 3fi, fi) <"■"'* fn'iu 

^1' iinriTiw iinU'ijcir Hiirfuc-i' nl tin- I<i«it Iwu-thiiils of ihi- ohttft of 

miildlc iii*?tiH'ur]>iil liotie. ami i» nuriifil iiit» lhi> inntT *i<le of 

l>a/)e of thu fiivt {ihaliinx of the thiiiiil), ami iut<> tlir ti^miou 




the pxiciuiur aMtimli iiitviiiiHlii ; tht> niiiHcle fortiiiiiK a triuU(;le 
irith its bosf to the iihiar siilf. It Ui'ci'Hsjirilv voVi-M thn miiyclcit in 
be fii'st iiml iiToml itit<T(p»i<fOu< Kpuit-M (wliirli may l>e seen in port 

it* anU'tior liniiU-r), uml will liiivr to Ik- ilividcd to ■•xpoi'r them. 

Tlie Seep Branch of the Ulnar Nerve (Kig. 22, 22) ii> to 

tiTK'ed out, and will )»■ fniiinl to arise from the nlnar trunk near 
be pinifonu hone, and t» pimx with the pnifunda vesxelH ahuiiid the 
Jnor eiJe of the riKit of the iineiforin iiroooiw ami lietwecn Ihe tlexor 

cvis and the uhductur niininii digiti, giving hra>ii'he« to theve and 

tlie opiMjneiiK It llieii fornix an arch acrow the hotfcD of the 
Betocarpal Ixniet^, u('com|>anyin^ the deep palmar arch, and supplies 
be two innermost liimhrieales, the Hcven interossei muscK-ji ()iulmiir 
Hid dorsjil), the ol)li(|iic luul trannverxe adilnctors, and the deep heml 

tlie llexor hrevix pnUicis. 



Fit- 37. — ItuCTlinti nf luiiM'Iw of thumb (from Duchninr). 



AMii'tor tx'lliciii. 

0|M ■■■■«. , . 

(lilt \or brcvK. 

, Xci": :v-ii.iur acii-umli Oiti r* 

nodii. 



TduUnoui oxtcnaiun from nlxliiriDr 
mill fleior liravia joiiiini; tciidou 
of extciuor seeuuili intiniinlii. 



88 



DEEP PALMAR ARCH. 



Tlie Seep Palmar Arch, the U.'rniiiintion of the radial artery^ » 
conimetitt-a in the tirst inlerosseaua space iiiiinediately after passinfU^ 
through tlic inturval liutivi'eii lln' two heads of the ahdiictor indici*^ — 
It tiiuy be traced, with its veiiaj coiiiite.", running in the fihrea o ^t 

orijjin uf the luidurliir oUinuua pollicis lo emerge between the ndja 

cent horders of this mu:^ele nud the nddiiclor transversus poUicix. 

TLe deep areb has u shjjht eoiivexily towards the tin);ein, and i^^ 
placed at the Jmictioii of the hiuies with the .'•hafts of tlie nietuc4iq>aK- 
bones. It is completed by anastumosis with the deep branch of the- 
ulnar art*;ry. 

Its branches are as follows : — ^M 

1. PriricfpK pollicis, a large branch of uncertain ori>;iii, sotnetiuies^H 
arisiirg from the nulial at the back of the abductor iudicin, but 
usually on the jialinar side of the niUHcle ; it pa-Hses along the lueta- . 
caqial iMine of the tbuinb, and then bifurcates to supply both side 
of the tluunb superiiciaity. It ftviiueiitly receives an anastouioti 
branch fnDn the tiuperlieird palmar arch. 

•2. Jiodii'lis inilicif^, arising near rir with the last, runs on the ' 
palmar ii>]iecl of the abductor indicis to the forefinger, of which it 
supplies the radial side, receiving a branch of communication from 
the ."uperfiL'ial palmar arch, and nimsttmiosing at the ti^ of the tinger 
with the digital artery derived from the sujHirlitial arch. 

3. Small rfciirniil branches to the carpii.", anastomosing with 
branches of the anterior carpal arch beneath the flexor tendons and 
annular ligament. 

•!. Three iK-rforatinij arteries lo the dorsum, passing betweciq 
the heads of tlie three inner dorsal interosseous muscles to join tlifl 
dorsal digital arteries. 

5. Three inltrmttcnng arivriet, which run on the three palmar ' 
intcroDseous muscles to the ronta of the Hngers, and then onostoniose 
with the digital brandies of the superficial arch at their points o(J 
bifurcation. They supjdy the iiiteros^ei. 

The tendon of the Flfjor carjii raitialiii can now be easily traeed] 
through the groove in the tntiie/.iinu to it.s insertion into the base i 
the second and thiiil metacarpal bones. 

The Palmar Transverse Metacarpal liigament ])n3ses iul 
front of the heads of the metacaijial bone>, and is closely counected] 
with the sheatlis of the flexor tendons and the glenoid plates of the| 
metacflrjMj-phalaiigeal nrticulations. The lundiricales and the digilalJ 
vessels and nerve.s jja-is in front of it lo reach the fingers. It nius(| 
Imj divided to follow out the interoswji, which jmuhs beneath it. 

The Dorsal Transverse Metacarpal liigament is a conipara- ' 
tively delicate baud of tibrca joining the heads of the metacarpal 



idetfl 
oticH 

•he" 
it 
)m 
;er 

th 



THE INTEBOSSEOUS MUSCLE.S. 



89 



« posteriorly. The tendons of tbe interoasei of each s})ace run 
tbrouj-h a ItinJ of sht-atli fnvuR-d ))y tht; two tnuiKveree li^amentH 
•tt'l the iiietacaiiml botifs wliich they connect. 

The Interosseous Muscles nre seven in number, three palmar 
>ud four •li>ri«al. Two of the juilnmr inten>s8ci iire readily ween, but 
•he luMuctor pollicis must be entirely detached from the ndddle 



Fijr.38. 



Fig. 39. 





Tile Tlirfe jMihimr inUrooxl (Fif^. 38) we muscles jilaced in the 
llilte ineLttcarpnl spaces between the fingers, and ure numbered 1st, 
^, lad 3nl from the mdinl side. They lire nrmnged aa (uiductors 
if tbe fingers to un imaginary line prolonged through the long or 



' ' 38 The three palmar intiTonaeons inuArlei of the hnnd {dravrn by 

J. T. Gray). 
I- Ttsdon of flexor carpi ulnnri*. 2. Tcnilnn of flrxor carpi radialis. 

Fig. 39. — ^The four donuil intfronaroux rau«-lo« of the hand (drawn by 
J. T. Gray). 

i. Tmdon of Mtonior carpi rndialis 2. Tondnn of extensor carpi r.idiali9 
lon^r. brt'vifir. 

3. Teudon iif ext«>nBor carpi ubum. 




90 



THE INTEROSSEOrS MUSCLES. 



middle iiieUuaipHl bone, as follows : — The 1st [uilniar interoAWOUt 
luiiscle iirUrit from the ulnar side of tlif 2nd metawiqial bone, iiiul 
w jnerrlril into tla' ulnar side of tlie Inise of the corresponding lirrt 
]>halunx ; the 2nd nmcii from tin- nidiid side of the 4tli met.: 
bone, nnd is iuerrtitl into tlie radial side of the corrt'spou'liii- 
phalanx ; the 3rl nri*r» from the radial aide of the 5th iiietju;ir|pai 

Fig. 40. 



I 

t boUf, and is mwrfn' into tlie radial side o( the corresponding : 

I phalanx. Each muscle also sends an important expansion to 

I iidjacent side of the cnrresiioiiding e.\tensor tendon. 

I The Ji'oiir ihirml interoiuii (Fig. 39) are bipenniform ]Ull«c]l 

I arinut) from the adjacent siden of the nietacar[>al bones, and 

therefore i^ecn from the front by the .sides of the palmar mu^clen to 
Slime extent, but are best dissecteil From behind. They are arranged 
as (i/»luctiii> from an iniajjiniuy line drawn through the niiddlf 
nielacaipal Imue, and are thercfure iiixrrtnl as follow* . — The Ul 
(alMlii(t<ir iiidiii.x) into tlie radial side of the liase of thi- lirst phalanA 
of the fore-linj,'er ; the ind into the radial side of tin' base of thi- 
tirst phalanx of the middle finger; the ;iiil into the ulnar (tide of tin- 
same phalanx ; the 4th into tlie ulnar side of the hr.st phalanx of 
the ring-finger, each muscle, as in tlie case of the paltuar interos-sei, 
giving a slip of inKeiliou into the eorre«]>oudiDg extensor tendoo.*j 




Fig. II). — Att«c)iiiii'iit of .■>« interoueoiu mutole (from Dm-henno). 

II. Iut«roi<seuii8 miiM'li'. r. Slip pawinu: rnrwiinl to (</) ndsl 

i. Attttchrncnt to buw nf tiisl plm- «xteniK>r ti'iidnii. 

liitix. r. C'vntrul poriion of extcDtor tood 

• TliP long t'x(eu'*f>r tenilon of each Higit hence receives a tibroiis slip on «icli 
side. The thumb tendon from the ubductor nnd ndduetor polUcii, the iude\ 
tendon from the tint dunal and firat palmur interoMei, the middle linger tendon 



THE ACROMIO-CLAVICULAR ARTICULATION. 



91 



Attioii, — Tlie insertions into tlie Imse of tbe fir^t itlmliiiix (Fig. 40) 
Mulile iLf inlerosaei to net as flexor' of that pluiliiux, mid to give 
l»l«»l iiiMVement to the lingers to whicli they are nttaclied. The 
my ((/) sent forward to join the extensor tendon extends the second 
■d third ]>ha]ange.s ; and tliiis tlie action of llie iiilerosxci im Uide< 
•MSflinn to and alxliiction from the median line of thi' Imml, with 
"Mion of the lirst and extension of the second anil third idiidiiiiges. 
Tht lumhricjiles act in a similar manner, liut have nioic power in 
•Wtintiiiji the flexion of the first ivjudiinnes, ami they .strengthen the 
"•li*! side of the nietaaiq)o-]ihfthuigeal juintJS. 

Thr whole of the interossci are gttpplicd by the ulnar nerve. 

[Tlif interosiseons muscle,-! of Ihe hand ^hfiitld he Cfimpnred with 
tbiKe (if the foot, wln-n the s;iiiie anviiigfrnent will ^n• found to exist 
'nbftlh ca-ses, with the exieiilioii that, in the foot, thi- inmijimtry lino 
'"rabiinclion ami adduction is drawn through the long nr ntcoinl toe, 
llif iuascle» being arranged in accordance.] 



LlOAUGNTK OK THK C'l.AVICLF. AM) SLAftI..\. 



fTlie nnii-cles about the sc«iiilla are to he fullowed to their exact 
'"•iTtionB and cut short ; tlie deltoid and the remains of the Impezius 
"lUdt be mrefully removed in onler that the ligainentu of the scapula 
Ml! rhivicle may be >ee!i.] 



I The Btomo-Clavicular Articulation i- a dmilih' ginglymus 
wtween the inner end of the clavicle and the stcriiinn and first 
*»t«] cartilage, and its cavity i.'i subdivided into two jiarts by an 
Inlenulii-nlar fibro-carlilage. The capwh is formed by uiitcrii)r anil 
f^rrtnr ttfrno-clariruliir ligaments, and is stretiglheiied by an inter- 
'krietilar ligament ab<jve, and a ((w/o-WoriVii^ir or r/ifj»(/i(nW ligament 
litjow. These structures are dissected with the head and neck (see 
^Anterior Triangle). 

Tile Acromio-Clavicular Articulation ( Fig. 41) is a rotarv* 

larthnMlial joint, with an iiitvr-uiticular liliio-cartilage, usually im- 

ipcrfect, but occa.iionHlly tomplete and dividing the synovial cavity 

uDto two parts. The joint fiasiire runs .str.\ight from liefore back- 

«nl*, and the articular surfaces of the Ihuu-s aiv so bevelled as to 

iirour ujiwurd dLsplacement nf the clavicle upon the acromion. 

The SiiltTwr airomiti-rlariciilar tiyamimt (l) is a (luadrilatcnil 

ad of short Htrong fibres, more or less connected with the fibres 

tb<> Kvond and third dorul iateroiuoi, the rint; finger tendon Fram the 
ad palnur and fourth dnnuil intt'ro.tsei, ami the little Sn^-r tendon from the 
1 paloiBr intero«cou8 luid thr ubduitor minimi di^ti. 




I 

1 



LIGAJfENTS or CLAVICLE ASP 8CJLPCLA. 

of Hm tn(>eziuii anil d«ltci(i. It U in reality eontinniMH 
h^rniar luroinio-claritular ligament, which i» rimjlar is thmfe, imt 
jtateA below Uii.- jnint, the two fonuing a capsule. 

The CorftoO'Clavictaar Ijigament (Fii;. 41, 2, 3) it itally 

Fig. 41. 




hut (ini> lt;,iiiiu'iil Iwlitwl upon itself bo iis to present two aaitm 
to which llie imincH Conoid luul Triipezoid have been j^ivcn. Til 
two ]iurt5 ttru i)(-|iiirulc-d hy the insertion of the suliclavin^ imil by 1 
biirwi. 

Tlie Conoid Ugnment (3) is the jiostcrior portion, and reoembM 



Fi(. 41.— Ligunnit* of the icapula and ahouMer-joint (from Wilion). 
1. 8up<Tiar iicroniia-cltTicuUr liga- 7. Coriico-biinu-nil ligKment. 



meni. 

2. Comcft-rUviculiir lignmcnt (trnpo- 
loid). 

8. Conico-cluvii'uliir lit^imciit (co- 
noid). 

4. Corwo-acroinUil lic«iiient. 

5. Tran»vcr»e lipiini'nt, 

6. Cn]»uljir liguinent. 



8. Till' Innp toiidon nf the bice] 

iwuing from the capsuliir lig 
nient and i-utrring tfau bicipifc 
Kroove. 

9. Evtm cjiptulur portion of should 

wnki't, formed by under «ur' 
of acromion imd coracOH 
mial ligamcat. 



LIGAMENTS OF CLAVICLE AND SCAPITLA. 



93 



aconevitli thi' base upwards. It is attached to the ]>08terior and 
ioiirr pMii of the base of the ciirncoid pn«;cs8 helmr, and to the 
tubtivli; I'n the uuder surface of the ilttvicle iiiul pait of the 
•"Ijiia'Ul IkiUc ahncr. 

TLr Trvjirzoiil liijainrni (a) might be more tuitubly callftl rliom- 
lioiil fmni iUt i«hii]>e. It iii a ijuailrilutt-ral band of librt^ii nttached 
lo the line on the {>o«t«rior port of tlie uppiT surface of the coratoid 
ptooM W<rtr, aliil to the line leading to the tubercle on the uuder 
•uiftce of the clavicle aliovt. It is anterior tuid exteniid to tlie 
fuaoid ligament. 

Thr Coraco- Acromial liigament (Fig. 41, 4) is a triangular 

Wnd ittached to the outer side of the coracoid process, and by its 

•nailtr end to the tip of the acromion process, and often jin'.sciitg a 

tltft through which pa«8e!> a vessel and occiujionully a .nlip of the 

talis minor. It arches alwve the shoulder-joint and jneveiits 

ocdtiiin upwanl?. It is loosely stretched between its two attach- 

:l> in onler that it may adapt itself to tfie mrve nf the Iieud of 

le linraerui*, for which it fotins, together with llie acnnnion, a 

ppltuientary socket. 

Uw Transverse Ziigament (Fig. 41, 5) is a short band con- 
the PuprH-.'<iii]iulur notch into a hole, and giving origin to 
!»rt of the omo-hyoiil muscle. It is often divided into two parts 
liy the KU]ira-scapular vein. The supni-scajiultir artery goes over 
ftt Ugameut, but the nerve lieiieath il. 

MiiTfrnml* of < 'lavievJar Joivtii. — The flmiii-ihivirtitiir joint is the 
•tolre for the uiovements of the entire shoulder girdle. It ndniita 
otion of the clavicle forwanls and baikwards aronnd a vertical 
and upwards and downwards around an anlero posterior axis. 
* hone is ruivd, and with it the scttjiula and humerus, by the 
"jiper ]>art of the tra]ie7,ius, the clavicular head of tlie sterno- 
tkido-niHstoid, the levator anguli sciipuke, and the rhomboids. It 
»JrfirfHiril by the weight of the arm, assisted by the subclavius, the 
J*<'U)ralis minor, the h)wer tibn;s of the tnipe/ius, and (indirectly) 
V the latissinius dorsi. It is drawn /on™ iv/ by the serratus magnus 
the sternal fibres of the pectondis iiuijur and hichrnril by the 
boidei and trapezius. The two clavicular Joints thus share 
[Ittveen them movements in all directions. 

The movements of the (KTomio-tlaiiciiltir joints are aluo verj- 
iporljuit. The scapula rotates around an axis passing through 
clavicular facet m the direction of the iniig axi^ of the clavicle ; 
i it i» this movement which alluw.s the foiwttrd movement of the 
L to 1>e carrietl above the level of the t^Iionlder. The forward 
in cauaes the glenoid cavity to look ujiivurds, carrying vf'vVV 




94 



THE SHOULDER JOINT. 



it the Lunienis, and is cffecte<l liy the lower digitatioDS of 
Hcrratiis uiaftnus. aided by the upper fibres of the trapezius ; 
oppiwiU; muvi'iiieul i« ilut- to the rhomboideiis major. 

Thk Shouujer Joint. 

[The miiacles HUrromiding the shoulder are to be carefully n<move 
those whiili we ijisertcd into tlie tul>ercle8 of the humerus beinj; di«^ 
reeled lis cIosl- tu the uiipsulnr liguim-nt as possible without iiijiiriii;; 
it, and then cut short.] 

The shoulder is un 'iiarthrodiiil or boll-unU-sockct joint, iiive 
Ijj' a ojipHular liganieut. It is surrounded and strengthened by til 
following muscles : — aboif by the supni-spinntus, Utow by the lo 
heatl of the trice|>s, iu front by the subsiapulari-s, and litkuui 1 
I he infm-spin!itu.>< and teres minor. 

MovKMK.NTst. — The choulder-joint admits of tlexiou, extensio 
abduction, adduction, rotation, and circumduction. The humerus ij| 
fl-utd (in front of tlie trunk) by the jieetoraUs major anil coraco 
brachialis, the anterior fibres of the deltoid, and the biceps. It 
rjirtided (Ijehind the trunk/ by tlic lati&simus don>i, tere* major and 
minor, and |Kisterior fibres of the deltoiil. It is adiluiUil by the pccto 
i-alis major, lati-isimus dorsi, the two tcre* musole-.. coraco-bmchialiS| 
long head of tricei>s, lower fibres of subsiapulari-s and slightly by 
the short head of the biceps; and uMiti-tnl by the deltoid, «upti 
>pinatus, and the long hea<l of the biceps. HvlutioH uuhrartl* is pr 
iluced by the infra-r-piualu.'* and teres minor ; inwardt by the supr 
"pinatus, su1>scapulariii, teres mujor, latis»imus dorsi, imd pee.tonilii^ 
major muscles. The bust two muscles are antagonistic in the f* 
that the [(ectorali.s major draws the arm fi>rwar»l acitws the chest,! 
after rotating it, whilst the latissimus dorsi draws it liehind t)i« 
liock. The range of the movementi of the hunieru.-; anjuud the 
three axes — s^igittal, frontal and ventnd — is from only 90' l» 100*J 
for each. Alsludion and llexion of the ann are hence efi^ecUxl onlj 
in part at the shoulder-joint, the rest of the movement taking plac^ 
at the Htermi and acromiix;la\icular articulations. 1 

The Capsular Iiigament (Fig. 41, 6) is seen to be loose, alio* 
ing jiartiul dLfcJocatiou of the humerus now that all the muscles i 
divided, and there is almost always an opening on its inner sid 
above the su1isca]>ularis tendon, by which the bursa of the sut 
ncupularis comunmicates with the articular cavity. The capsule i^ 
attached u/w/rt- to the outer margin of tlie glenoid cavity of tl 
•oualO} and hdmc to the anatomical neck of the Imments, exc 
' ner side, where it is prolonged downwar<ls aa for as 



THE SHOULDER JOINT. 



95 



"til^ail neck. It bridges airoris the biciiiital gnxive, k-aviiig an 
«l«rtnre for thu long tendon nf the biceps (Fig. 41, 8). It is 
lhickein!d in front by an accessory buml of Hbvea, the Cortico-hnmKriil 
ligamtil, atUche<l above to the hiwer jmrt of the piisteiior border of 
'he ooracoid process, and below to the fireutrr tuljcittsity of the 
liiUDmis. This band Ls rexunle<l by Mr. Bhiiid Siittou as a degene- 
ntioa nf the |>ector.ilis minor tendon, a slip from which occiisionally 
Mchei it by jnercing the cornco-aiitmiial ligament. 

The Ulniii-hnmrral liijiimrnU are accessory bands springing from 
llie anterior border of the glenoid cavity, seen ou ojiening the 
■""iwilefMin Ix'hind. 'V\n- »ii)icrii>r, narrow and riniiulcd, is attached 
ibovc to the npjx-r jiart of the anterior iiiai^iti of the glenoid 
«vit)- in front of the origin of the long head of the biceps, and 
Wow to the n]i[KT part of the lesser tuberosity of the hiiiuerus. 

Fi(t. 42. 




. 43. — Diagrunnutic MCtion of shoulder through bicigiitid groove (\S'. A.). 



i Deltoid. 

; Acromion. 
Su>>acr>:>niinl burwj. 
Gliiiuid li^pitneat. 
Capaiile of alioulder joiut. 
Glenoid ciirity. 
Luog tendon of biceps. 
Glenoid U^inrnt, 



9. Sjmoruil niembrnne lining aipsule 
and rnalicathiuj; biceps tcudon. 

10. Inner fiiM of cniifulc and ajnoviid 

ruDnibmnc. 

11. E.\tni-iuiiculnr portion of biceps 

trodou. 

12. Humeniii. 



THE ELBOW JOINT. 

It b MipjKJMd tu rviirescnt tliit linmnentun teras of the laae 
aticmhr. The inferior gkno-hutiieral lipunent, hraad aod ttttof, 
nwf &vin Ibc ]owrr luUf of the aiitenor bonier of the glcaoid csritf 
to Uie anUrior uul inner Mile of the neck of tL« blUivenM. A 
mUiU band i* KOUir-timeH <]e«criV>eil lietween the twu f<M«(;oi^ 
ttkiag with the ouiH-rior uml ultuched below to the inner Mt of 
llw IcMtf taheroiity. 

The tendon '>f llie biiM-pH is to !« followed into the itrticulotion It 
ng ayeu the capvuliir li^'aiuent. It will be found invested Iit « 
tube of irrnorial iiiembrani-, unci ottuclied to the ^{lenoiil li|,>aiiit'ni mil 
ll|^erport of the glenoid cavity. Its synovial sheuth can l>e deJium- 
ifelilM 1>cfoiv the rfljHiiile in opened by muking tmetion upon the 
tendon during tlexion and abduction of the ami, when the lower 
jiortiuM of the Inlie emerges from Uie bicipital openinj: {Fig. 41). 
Thi» ihoiild lie remeniliered in aniputjition of the ana thrr>ugh thu 
•urtjiral neck of the humerus, when the tendon is divided, »s other- 
wix; the joint niiiv l«- ojiened. 

The Olenold Idgament (Fig. 42, 4) in 11 fibrous ring continu- 
OUK with the Ivndon of the bice])8 and attached around the bonier of 
the gh'niiid c-avity, whiih it therefore deepens. 

There i« u single Synovial Membrane in the .shoulder-joint, 
which in rellectetl over the glenoid and capsiUur ligftments ami 
around tlie tendon of tlie bice])ii (Fig. 42). 

The Eluow Joikt. 

[Tlie luuHcle* about (he elbow are to be removed, and gri<at coiv 
must be tikeii, in detividiiii;; the supinator breviis, not to remove or 
dainagi' the external lutcnil iiml tlie orbicular ligumfiits. Beneath 
the triceps clo^e to llic j<iiiit iiiiiy Iil- found a little slip of muscular 
fibre uttiicheil to the lower end of the humenis and the l«uk of the 
joint; this i" the .s'i/'«(n<-«»'i((i, which is however often watiting or 
but ulighlly developed. All tlie muscles of the fore-orm anil hand 
should now lie ivnioved to facilitate the exaininution of the wrist, 
&c. In removing the deeji muHcles of the fore-ann, care niiif.t lie 
taken not to injure the interos-seous membrane and the oblique 
ligament.] 

The joint lietween the humerus and fore-arm bones, the elixiw 
joint proper, is almost a pure giiiglijmH* or hinge, and is provided 
with anterior, posterior and lateral ligaments. The 8uiM?rior radio- 
ulnar articidation which is continuous with the elbow joint is on 
example of itiurthrumn rolalorius, the bend rotating in a riny forme 
portly of Ixjne, partly of ligament. All these ligaments unite 
form one general capsule enclosing a single synovial cavity. 



THE ELBOW JOINT. 



97 



The Anterior laigament (Fig. 44, i ) is a l>roail but thin 
metiibrani; uttAi-hwl to lln' luimcriiH initiKMliiilt-ly above the coronoiti 
Atiil rnilial toHxti', atui below tn ihe coroiioiil prucegD of the ulna, a 
littli" ln'liiw it* edge, nnd to ihe Iront of the orbiculiir licriuiieiit. 

The Posterior Ligament in thin and loose, und i.s iittimhnl to 
the humeruit above the ulernmon foBsii and to tlie external ami [Mistcrior 
borJft* of the olecrnnnn jn^Kevi of the ulna, a xhnrt distance behind 

Viif. 43. 




srtirular nurfttce. lt« ntrou^ert fibres unuully form « transverse" 
briii^^ing ocniss the olecranon foma. It i,'ive» uttiichment by 
its posterior Hiirfnce to a few fibres uf the tiicepa (tiitt itncontiit) und 
auteriurly i* i.onnectol with a /jlica adipuia which tills the olecranon 
fuMui during flexion, but is drawn iipworda by the siib-anconeui in 
extension. 



Fig, M.-^Stx-tion u( rlliow (rroin ISrauno). 

1. KippTw. <». Supinator l)rc»ii. 

J ;i«. G. K.\trn>or cu'pi tudinhs lungior. 

iii-rro. 7. Kxli'ijuur curpi ulutiri*. 

1. ,, . „.i5. Jt. Triceja. 



ffir M. 




TW Wxtemtl I<*t«r&I Ligament (Fig. 45, 3) i* a sluoTt I — ^ 
Wftl Mlaclml to Uw Imrer part of the outer condyle, aad nwlkting 
I* Us attaduKM to Uie </rbicular ligament of the adint, uA 



Vtg.*t- 



■ <f tlie eHiow tnm the inner ride (ftm Sapper), 

•• A^mtm tt^mimtL 4. Intenul lateral ligament. 

S- I t — I «iil^le. 6. OleeraDon. 

a. ||ai4 t4tmbm Mrared by orr<>inilu' ligament. 

W*- •*• — LigMBciitj of the ribow from the outer nde (from Snpi>ey). 
I. Mt^VMal cmtfjrW of humeru*. 4, InteroMcoui membmnu, 

S. (hMMdwMgMDart wrrrjng head 5. OlFi-ranon. 

(liaAak 6. Oblique linment. 

». tgunmi lUfiBt Ufmmt. 



THE ELUOW JOINT. 



99 



iniew of the lesser signtoid cavity of the ulna. It gives origin to 

of the HUplnator brevis and esctcnwir cjirpi ratlialis brevier. 

Tlie Synovial Membrane comnKm tci tUu elbow ami superior 

in-nlnar juinta '.vill lie seen by removing the anterior ligament, 

Wd will lie found to be reftcctcd upon the inner stirrare of the 

.Cljisnle, including the orbicular ligament, and upon t!ie bones aa far 

M Utt margin of the articular cavity. Well marked plicoj 

ttlipnas are funned by an infolding of the synovial nieiidjraiie and 

•ulaynovial fi»t opi>o»ite the joint furrow.i and in the position of the 

hsnienl fi>*»io. A very large one fills the oleiiuiion fossa during 

'lesinii, and smaller ones orcupy the coronoid and radial foHsaj 

'liiriu;; cxteni'ioii. The urticuhir surfaces of all the boiie.s are 

I'Dcrurted with cartilage, but oc(^isionally a groove across the 

Imltoiu of the greater sigmoid cavity separates that covering the 

"Ifcmiiun Irvm that covering the coronoiil process ; this groove, 

fbifli is seen also in the macerated bone, must not l>e mistaken 

firUie remains of the epiphysial line. 

Relations (Fig. 47). — -The elWw joint has t» frtmt the brachialis 
WticiH and bicejw, the inner Imnler of the supinalor longus with 
''><' luusculo-ttpiral nerve and the termination of the superior pro- 
lOiiilji ttrtery beneath it, the pronator teres, the brachial vessels, and 
'w iiKilian nerve ; lirhiml, the tiice[)s and unconcus muscles. To 
'be inner side, the nmscles arising fruin the internal condyle, and 
"« ulnar nerve, with the inferior jirofimda artery, lying upon the 
•Ntemal Literal ligament after passing Iwliind tlie internal condyle. 
^miillu, the muscles arising fn mi the external condyle and supra- 
Wtiilyloid ridge, and the supinator brevis, which is closely connc*cted 
*ith the exlenial lateral ligameid. 

JfovKMESTtt. — The lore-arm is JU.inl by thi' bicejB, brachinlis 
witicus, supinator longus, extensor carpi nidialis loiigior, jironator 
.lidii teres, and (feebly) by the flexor carpi radialts, palniaris longus 
flexor digitorum subliniis. It is rxteiulnl by the triceps anil 
iticoneus, and slightly by the extensor carpi ulnaris, extensor digi- 
loruiu communis ami fxtensor minimi digiti. HitUiUon of the ntdiiu 
iijion the ulna and humerus, and consequently a portion of the 
ttiuvenients of ]>i-onation and supination of the hand, are prtsluced 
follows, — Pnmnlioii by the jironator ipiadratus, pronator teres 
flexor carpi radialis, Kiipinalinu by the biceps, supinator brevis 
eitenaor ossis metiicarpi pollicis (ulnar heiul) and extensor secundi 
intemodii pollici.s. Tbe supinator longus ha* no influence of im- 
portance upon pronation and supination, but probably acta slightly 
in bringing the fore-arm into the position of Bcmi-pronafion when 
the elbow is flexe<l. 

H -2 



Hi 




■ ^^^^ 



100 



THE ELBOW JOINT. 



The rotation of the radius around the ulna in pronation ud 
Kupination la associated during life with a kind of circumilliction of 
the ulna, c-tfected hv movements of flexion, extension, abduction, and 
adduction that are almost imperceptible at the elbow joint, but tn 

Fig. 46. 




easily wen at the wrist. Tliey tannot, liDwever, \te deraonstral 
by passive rotjilion of the mdivis in the dead subject. 

It must be I ecolk'Cted ihiit tliu entire movement of litind rotation 
is equal to 280", and that not more than 120° of this is efl'ected at 
the rndio-ulnar articulations. The rest is aecouiiilislied chiefly al 



Fig. 46. — The elbow joint vxpoaed from the front. 



I. Cephalic rein. 

'2. Biuilici vein iind iutcmal cutaneous 
nerve. 

3. Miii!iiilii-e|iiral nerve. 

4. MtMliuu nerve. 

a. Bruehinl iirtery iinil vcnn comites. 
B. .VnKBtiimoticii mngna. 
7. Rttdiol rccuncnt. 
H. Meilian vein. 
A. Biccpi. 

II. TiiceiM. 



c. Supinntor longna iind extenuir i-arp 
rediidis lonsior (tlie divi«ion w- 
tween thom is not evident enough). 

I>. Origins of fle.xun* and pronatora. 

E. Capsule of joint. 

I'. Ext«n.-ior carpi ntdioUa longior. 

0. Pronotor teres. 
H. Supinator longu). 

1. Tendon of bireps (beneath wli 

arc the brachialLs uuticuia and 
lapiule). 



4 



THE ELBOW JOINT. 



101 



ike ilioiiIdeT joint (about 1 00°), the carpal joints, and, in exaggerated 

llttioii, even liy the movement of the scapular arch antl s]iiiial column. 

During full extension of the elbow rmlv the anterior liunk'T of the 

M\i\KT surface of (he radius rests against the capitelliim of the humerus. 

The movements of llexion and extension nl' the cllmw take place 

inwnd an axis passing through the lower enil of the humerus from 

condyle to condyle, but with u «light incliiintion (lownwar<ls ut iu- 

iMier extremity. As a result of this oblitjuity, the hand lies in a 

pliue internal to that of the head of the humenis when the fore-arm 



Fig. 47. 




" (ally flexed upon the upper arm, and during complete extension 
'it «nu and fore-anii join at a verj- obtuse angle, the opening of 
•liicii is directed imtwartls. The total range of tlexion and extcii- 
>iia 11 about 150°. 

Radio-Qln'ar Articolations. 

Superior (Fig. 45, 2). — This is a part of the elbow joint. ItJt 
only ligament is the Chrhicnlar (Fig. 48, 3), a strong Hat band of 



Fig. 47. — Tr»nn'er»e section tlirougli liumeruii and olecranon. 
11. Oriirin of I'XlfuBom, 



1. Supinntur biigus. 

'i. Ilnchiiil »rt«n' with renn comitct. 

3. Tendtm or bit-rpff. 

4. Pronutor Utc». 

a. Musculu-«|iiral tiprre with supe- 
rior pntfuiiilu urtcr)'. 

6. Mcdinii nerve. 

7. UrmctiiiUis unticut. 
t. Orifin of flexoif . 

l». Inner condyle. 



I'i. IntoniHl luti-ral lignniput. 

13. Outer condyle. 

14. I'lniir lu ne. 

Id. I'osterinr iateroMoous recurrent 
vessels. 

16. Posterior ulnw recurrent venels. 

17. Anconeus. 

18. Ulecranon buna. 




V 





[11. i<- iilli'l 
in tlifW 




L 



102 



THE WRIST JOINT. 



Fig. 48. 



fibres encirolint; the bead imd neck of radio?, and attached to 
txtreniities of the le.s8er sigmoid oavity ami Hliyhtly into the ni 
of the radius. It Ideiids with the exteniul lateml ligament of 
«dl»ow, aiid gives orij^'in to fibres of the supinator lirevis ; the joL 
cavity in roiitiiiuous with that of the elbow. 

Inferior (Fi^,'. 49, 3).— The Ixines are coiinectwl l)elow 
anterurr ami iKKtrrim- ligninent.'*, short fibi 
luimls ]>a!<Hiiig between the borders of 
si^Tiioid cavity of the radius nntl the head 
the ulna internal to the articidnr »urfaci 
iind by an inlrr-articular jibro-cartiliuje w 
will be seen when the joint i.s opened 1, 
51, 3). The synovial niembi'ane (wirwii 
mrrifimn ii) is very loose and contains a gi 
deal of lluid. 

The InterDKMOiu ligament or niembi 
(Fig. 4."), 4) is the great bond between 
shafts of the bones of the fore-ann, its fib] 
running for the most part obliijuely do' 
wanls Innii the nidius to the ulna, but sonie 
in tile ii|ij)usite direction. It is attached to 
the sharji interosseous Ixirders of both bom 
a space being left above, lictween it and 
oblique ligament, for the passage of the pos- 
terior interosseou.-- ves-sels. The membrane is pierced below b] 
the anterior interosseous artery, and one or two of its brani 
(Fig. 4i), 4). 

The Ubliqut; lujiniimt (Fig. 45, 6) is an inconstant band, running 
from the outer side of tlie tuberosity of the ulna to the radius lieli 
tlie bicipital tubercle. Its diructiou is therefon^ the reverse of 
of the principal fibres of the interosseous membrane. 







Thk Wrist Joist. 



8 lieloi^H 
of th^l 



The term " wrist joint " is somewhat loosely applie<l by anatomists, 
and may be taken to signify either the rad in-carpal joint, or the 
whole of the articulations into the formation of which the carpal 
bones enter. 

The Radio-Carpal Joint is modified ginglynius admitting 



Fig. 48.— Upper inrtof uhia with orbiuulur ligttment (from Wilwuj). 
1. Olecmnun. 2. Tip of i-oronoid prorc**. 3, Orbicular lisiime 



THE WKI8T JOINT. 
Fift. 40. Fig. oO. 



im 




Fij. 49. — IJ|pitu(rut» of Ihcantfrior iM|ic-i't of tlic wrint unil liuml (fmin Sapjey). 

1 Ratliu*. a. InternnI Intrrul lig'iinvnt of wrist. 

2, lDt<>rti«eouB memhnuif. 9. TiibtfrcU' of ik-aphoid. 

3. ArtieuUtiun betwix'n Iowit eiul of 10. I'isifunii boue. 

1 [. 'rni[»e/iuiu. 

12. Hook of unpifomi. 

13. ArticuUtirin betwivii trapezium 
iini] tii'«t inftjiriirptil. 

H. Anterior lipinicnt of t-nrpiw. 

US. J.it:iiriienta unitinR mrtiiinrpnls 

with one ituothtT iiiul witli 

rarpU9, 



Ratliuf. 

Intoroaaeous meinlinuif. 

ArtieuUtiun betwix'n Iowit eiul of 

ulna atid triangular tibro-eurli- 

bige opened. 
hjia<.« for itut«ri<jr intcroMoou.'i 

urtrty. 
Ext^miil latent! lignmrnt uf 

wriil. 
Lower end of ulna. 
Anterior ligament of wrut. 



fig oO. — Section abowiiiK the diipoaitiou of the chief gj-Donal membiunu of 
tne wnst-joiiit (from Wileoii). 

(The reflection of the nipiubraiica over the articular cnrtilagea is crroocoiu. 
It ihould coviT only the lipimciiluu* structure*.) 



I. Saccifomi menihr.ine. 
II. Second «\nn%ml uieinbruue. 
111. Third or lurjse njUMvial mem- 
brane, 
f. SynoriKl niembraot lietwceu the 
lr«{>exium and metiicHrpnl bnuc 
of thumb. That of the (liaiforiii 
Iwnr it not riisible in thiariew. 
, 8>iio\*ijU uieinbranv between 
uncilorui und two inner niotu- 
carpaU. 
Kuliuit. 2. Ulnii. 

Internal lateral ligucurnt. 



4. Kxterntil lateral ligament. 

5. Cuiieifonu boiii'. 

ti. SemlluniLr. T. Sraphoid. 

8. Unciform. 9, llji mct^^nun). 

10. Trapezoid. 11. Trnpeziuni. 
12. Intirarliculnr Hbro-cnrtiliigi'. 
Vi, Aletjicurptil bone oT thumb. 

11. Mctiunrpiil bone of little finger. 

•, . Inler<»fr»»eou* mi'tiieuqml li};''- 
tiii'iil>. [ntcroBN'oiKi lipimeotJi 
iu*e iiltu) Bei^n eouuiH'ting the 
boneft of each row u( tbe carpui'. 



104 



THE WUIST JOINT. 



flexion ami exU-iisioii witli Kome luternl und rotatory move 
and Las anterior, posterior, and two lateral ligauie]it«. 

The Anterior and Posterior liigaments (Fig. •19i 7) »« ^'p 
bands altiicbed al>ove to the front and Imck of thu lower end of 
radius, and below to the front and back of the first row of 
bones, blendinjj with the ligaments of the carpus. 

The External Iiateral Ingament (Fig. 49, 5) is a tliick 
attached to the styloid iirocess of the radius, and to the outer side( 
the scaphoid and trapezium. 

The Internal Latere^ liigament (Fig. 40, 8) is louger th 
the external, inid is attaclnd Ui the styloid process of the uina, ; 
to the cuneiform ajid pisiform V)ones and anterior annular ligaiuen 

Relations. — It has in fnmt the tendons of the flexor long 
pollicis, llexor caqii radialis, i>alinarts longn.s, flexor oublimis 
profundus, and flexor carpi ulnaris, with the ludial vessels, 
median ner\'c, palmar cutaneous nerves, and the ulnar vessels 
neiTC. To the HUtcr side, the tendons of the extensor ossin luetl 
c«rpi and primi intemodii pollicis, with the radiid vessels, crossil 
obli(|uely from tlie front. JUhind, the tendons of the extensor ca 
nidialis loiigior and the brevior, extensor sccundi intemodii pollicy 
extensor communis digitonim, extensor indicis, extensor mini 
digiti, and extensor carju ulnaris, with the nulial nerve, the dor 
branch of the ulnai' nen-e and the terminal branch of the posterid 
interosseous nerve, as Mell as some small vessels (Fig. 33), 

The ligaments connecting together the carpal bonea 1 
very numerous and scarcely repay a special dissection. They 
be classified as follows : — 

1. Ligaments of the upper row : 

Dorsal, Palmoi', and Iiiterosseous, running Wtween «i 
luiuir and bones on either side ; Capsular, between pisifoi 
and cuneiform ; Triuisverae, between scaphoid and cuni 
form, pa.ssing across back of head of os niagnuni. 

2. Ligaments of lower row r 
Dorsal, Palmar, and Interosseous, connecting each bone with 
its neighbours. 

3. Ligaments connecting the two rows with each other : 
Dorsal and Palmar. 

External Lateral between scaphoid and trnj)ezium. 
Interaal Lateral lietween cuneifonu and unciform. 

The Medio-carpal Joint between the two rows of carpal 
ifl one of great importance, as the movements of flexion and e; 
sion of the hand are shoi-ed almost equally between thia and the 
radio-carpal articulations. 




J 



THE WKIST JOINT. 



105 



HovEMKXTS OF Hasd AT WuiST. — The hand is /«x«£ (90°) at 

*•"« nulio-c-aqml ami me*lio-carpal joints 1)_v the Hcxor carpi nulialis, 

^ne Jleior carpi ulnaris, the superficial and deep flexors of the 

"Ogtrr- juid thumb, the extcnHor ossis nielacuqii pulliciH and the 

Hensor pritni intcmodii pollicis. It is utauleil (60") at the same 

liculation by the two radial carpal extensors, the extensor carj)! 

■is, the common and special extensors of the fingers, and the 

Uensor secundi iiitemoilii pollicis ; the range of motion being 

St when tlie fingers are Hexed. It is aMnrted (2.5°) at the 

dlixarpal joint only I'V the thumb extensors, the flexor caqji 

adialiw, and the extensor carpi radinlis longior; and isaddiicUd (55°) 

ly the flexor iind extensor curjji ulnuria. Tlie rulatary movements 

■HClKted M'itfa pronation and Bupiiiatimi are effected by those of 

the pronatois and sii])iiittt(ir;i that are attiuhed to the hand. 

Tile Superior Metacarpal Ligaments (Fig. -*9, 1 6). — The 

ind, 3ixl and -Ith metacaqud l>une.« are cciuected with the lower row 

'if the curjms by doTtul, jtahn'tr and iiiliroanfous H^nments, and by 

' i.iments running from tin.' jiisil'orm and annular process of the 

rin {jnto- and hamo-mclaatrpul'j to the 5th metacarpal bone. 

line mclacarpnl bones are joined together by tntusverse ilormt, 

■', and interogSfOiiA ligaments. The lirst metacarpal bone has a 

tXe eajmilar ligament connecting it with the trapezium, this joint 

owing double angular movement with slight rotation. The joint 

tween the fifth inet«c4trpal bone ami the uncifonu perniit.s similar 

[iilar movements, but much more limited in range (Fig- 5t>, 13), 

he rtmaining carpo-nietacaqial joints are cajtable only of a slight 

ng or arUirodiul movement. 

I)e synovial membranes of the wrist are to be opened by the 
[lowing incisions on the doi-sal ».'*i>ect of tljc band : one between 
lower end.s of the radius and ulna (care being taken not to 
ride the libivi-cartilage), and three traii.'tverse il!ci^ioll8 carried 
tween the lower end of the radius and the carpus, the two rows 
canml Iwines, and the ciirpus and metacarpus resjiectively. The 
_^ticuLatious of the pisiform bone and of the first uietacar|ial bone 
are also to be opened.] 

The Byno'vial Cavities of the wrist (Fig. 50) are five in 
nmnlier. (1; between the nvdiiis and the under surface of the 
triaiigalur fibro-cartilagc above, and the three outer bones of the 
first row of the caq>us lielow ; (2) between the first and second 
rows of carpal bones, pa-ssing between the several iKities as well, 
■l«o between the second and third metacarpal bones, and the opposed 
cupol bones. It is sometimes sub-divided into two by an inter- 



100 



THE WRIST JOINT. 



Fig. .-,1. 



osseous ligaiueiit at the urticulutioii between the scaphoHl 
tra]>«2oid ; (3) iK-tween tlic cuncironn lunl piHirorra l)one« ; (• 
IwlWL'en the trui>ezuiiii and tint iiictucuriiol bone of the tbiiiul 
(5) betwei-n the unciform mid two inner metacarpal Imiies, 
sioniilly eontinii(>U8 with the 2nil. Tlie synovial uHvity Uetwi 
the lower eudsuf tlie nuliua iiud uhia lies iiIkivv the wrist, ami 
should not W included in the enuniei-ation. 

The Triang^ular Fibro-cartilage (Ki;;. 51, 3) is best 

after n.'Uiovin;< the mrpu* a]to^th( 
It is a powerful ligamentous struiitui 
iMxusionully perforate, and is attaci 
by its biwc to the margin of the rmli 
l)etwi'en the nliiur unil car|>al Hurfuci 
JUid by its npex to a dejiression cloxe 
the root of the styloid process of t 
iibui. It is in relutinn below with 
tuineiforni and 11 portiou of the 
lunar bones. 

The Inferior Metacarpal Iiiga- 
ments. — The distal ends of the foi 
inner nietacarjinl bones are joined 
gether by judniar anil dor^il Iransverso ligaments. The pal, 
ImiuivfrDi! ligament is of gntat stivngth and blends with the mel 
«ir[jo-phulangeal ligaments. The ilorud truiiscerm ligament is ma 
weaker, and is separalx;d from the former by a space which transmil 
tiie tendons of the interossei. 

The Uetacarpus and Phalanges are connected mainly by 
latend ligimients, but luilerior iind posterior liganientii ai«80iuetii 
recogniscil. 

The Aiitrrior li<jaiii<<iit is represeiite<l by strong fibro-curtiloginoi 
'lUvoui pUitfi ]ias8ing from the anterior border of the base 
the phalanx, to be loosely attached to the nietacarpid lK>ne j 
above the head, and cUisely connecteil with the ptlniar tninsve 
metacarpal ligament and Literal ligaments ; it assists in fori 
the sheath of the teuilons. 

The Posterior liij»meiil consists merely of n few delicate fibrs 
strengthening the synovial memliranc In^neath the ex{>ansion of 
exten.tor tendons. 




% 



Fig. 51 , — Lower end of radius und uinn with trianiruliu- fibro-oartiliixe (tMB 

WiUon). 

1. Kadiufl. 4. Articuliir 9urf»re of nuliiu. 

2. Ulna. 6. Menibntna «iu'ciforinls. 

3. Interarticulu- fibro-cartiUpj. 




THE WRIST JOINT. 



107 



The Lateral liijnmenU are strong bands which nre Bttached above 
** Ihe giiles of ihe heads of the niL-tacaiiial l>oin'«, and KjircadidK out 
w* a fan-like manner, ])ai!s (dilirjuLdy to the aiiti'iiitr mid lateral 
>u4r|^ine of the jihalanges, decussating with each utlier in fmiit of 
"»e joint, and blending with tiie glenoid jjlate. The strength of 
"It radial ligament !.•> greater thiui thai of the ulnar, and is reiii- 
'ttfted by the lumbriwilis. 

Eacli joint is jirovided with a »ipmtml iiu-mhraiu: which fumis u 
ciirul»r fold (plica adipoiMi) between tlie two bunes at the level of 
Ibc articular fissure. The articulation is ennrthrodial, and it* move- 
louiiii are flexion, extension, abduction, adduction, and slight rota- 
lioii. The latter motion occui-s only during circuniductiou. 

The Phalangeal Articulations are similar tu those between 
IJm metacarpus and phidanges, but tlieir movements are lindted to 
ikjdon and extension, and the jointti an.' henc<> ginglynmid. 

MovEMEXTS. — The MET,\rAKro-PHALAXtiE.\i- JuiNTs (exclusive of 
that of the thumb) are Jicjrrd liy the interossei and hiinbricales, and 
•eeondarily by the flexor subliniis and flexor profundus ; they aro 
aiUmJtd by the common and special extensors, and Idlentlm-il by the 
interMsej and lutubrtcales ((/. t'.). The i'halanueal joints are 
ilatd by the Uexor sublinus and flexor profundus, and ejJcndid by 
the interoasei and luinbricoles, and secondarily by the common and 
f^pecial extensors. In the ca^e of the LITTLE FINOEK the iiiuscIeH 
Dallied are aide<l by the sjiecial abductor, flexor bre\-i» and flexor 
(«$i» metacarjn miititni digili. It triust be renicniben-d, too, that 
there is a motion of about 15" in the direction of flexion and exten- 
tion at the curpo-iuelacar{>al joint of the fjiiger, and it i^ probable 
that the ulnar C4irpal tendons attnihed to tlie base of the metacaqial 
bone assist the long and short muscles of the digit in acting upon 
the articulation. The CAUiij-jvETAtAHrAL joint ok the thlmb i» 
lUad by the abductor flexor lnt?vis, lulductors and opjKinens and by 
the Jong flexor, rjcleiultd by the thrt^e extensors, tiMitct'il by the 
actor outer head of the flexor brevis and op]ionens, mliliieted by 
extensor ossis metacaqii, adductors, inner head of flexor brevis 
and Unit dori<al interosseous. The jiETACAKPo-rHALASOEAL joint 
OP THE THUMB is acteil ujioii by the same muscles, except, of course, 
those which do not reach the jilialanx. Tbe jihalaiitjfal joint is 
flexed by the long flexor, and extended by the long extensor. 



ue 

It 






^ .< 



u^^ 



>' 



(fc^ 



" .Si 



M 



E 
1 

s s 
■? - 

a 1 

? I 

I I 






s, ^ 



1^ 

3 



i 55 a' 

5.— 3 -a = 
e e; a c rt 

s I § j"-^ 

■"^li ..11 

•3 £ E * i 3 

c =3 c (5 - * 

X - i: = = fc'S 

-S s ^ ". - s ^ 

Si'i* 5?-= 

- - " s - 



P.s 






If 




v> 




^-^ S 2 = J e = i 



|i ^• 






5 ipiiiisijs fill! 






111 2. 



C' a. - o 3^ 5r 

,5 3-c-c.2-8j5f S 



i: 3 a « ^ t-j - 



■S-C 5:5:2 £.a 

u r* sj ^ "^ fc -^^ 



'.^e?! 



>,,«» 



PART II. 



I 



DISSECTION OF THE LEG. 

[Tlu titiuieni U reqiifdrd to retul Iht ' Introiluctwn ' before commeneixf 
tlu dutediou, unlfu lie lull done lo uH a preciotu occajiijn.] 

btrDKt, br^nning the actual digsection, the student should nuke 
biiiiiiclf fully iici|imint«d with the external e<mtirr]ifation of the part, 
•lid tliu rt'lalii'iiK which KUi><.'i')iciid ii}i]iearaiice8 War to (lr«p«>i 
•tniotun-t. If h<.' has already di»»fct«l this rt-^on, be sliould almi 
utakv the iuciKiuim neixaisary to expose the sevenil arteries in the 
poatiouB ill which they are usually tied, iiccortling to the direction] 
which iu:cuni]iany the description of each vetisel, tidcing care not tn 
dixturh the tihcnex tinneccsf!ari]y, oad to stitch up the incisiont 
without flfclny. 

Eitrmial iijipeuraiitt*. — The fold of the groin se]iarates the nhdu- 
taeii from tlie thigh -, and the fiuger, if carried along it, will 
retitgiiise /'on/Kirt'* liijaiuenl, stn-tched tightly ucross when Uie 
limb in fully extende<l. In the Banie position also the front of tlie 
thigh will be convex owing to the lai-ge extensor niu.scles, but if the 
knee Ik: slightly bent and the thigh abducted, a shallow depression 
will be seen imintdiulely below the groin corresponding to Sairjut'i 
truiiigU, aiMl Poujiart's ligiuiieut will be felt to become rehaed. 
Lymjiliatu ijUindt of voiiable %\w oui be felt along, or a little above 
the liue of Poupart's ligament ; whilst below it, and more or Ie«s in 
a verticjd direction, will be found others which belong strictly to 
the thigh. In the centre of the hollow on the front of the tliigb 
can be felt the f< mnrnl iirlery, which may be followed for about a 
third of the length of the thigh in a thin subject. At the fold of 
the groin it lies aluut a thiid of an inch internal to the miiKlle of 
I'ouparl's ligament. The napluKvut vein is uccasiuiially to be seen, 
when enlarged, on the inner side of the liuib, iiud the course of 
olliers joining it is Bometimes visible. If the body should be the 

aject of femoral hernia, ])robubly the herniul tumor will be found 
ig the upper part of the hollow in the front of the thigh, 




;b, J 



THK TJJKJH. 



113 



<Mta nSehing more or low hViovp tbu inner jiortioii of Poupiirt'd lign- 
inent. In »ut-h a cnse, if the licrtiiul prutniition Iw ^rtll^n(Ml, clir 
(inger rjin lie roiulily juvsM'd into tin- iMilnrgetl mjihirnniu tipeninii and 
up into the cmnil ring iH-binil r<piiinirt'x liguuivnt. 

TL>- cn-st ami tliv HiiUTinr >x\n\ jnwlt-rior ><ii|>crior npineii of the 
i/iiim will 1m? remlily •(.i-n Hiid felt ; tin* spine miil u-rcal of the piiljc.* 
can ulxu lie ilititingaulied. The tubcriMity of thu ijcAiiint i» nbitiniriul 
by the glnleus niuxiiuuH if the hip ix extemletl, but it may \w felt 
liialinctly during flexion, the muscle then lyin^ «1kivi' it. The yrtal 
troelianter ii» cosily reo.ognioed from three to four inuhen l>elow the 



Fig. di. 




|. 52. — Di«;nim •howin; Umlniurka for gluu-al ami aciutifi arteriM at tbslr 
P"iiit uf Hit Irom tlip pelvi« (W. A.) 



1. Gluti«l url 

ami mi'i 

po.:. 

rr... 

2. SouilK.--. 



t>n of utipvr 

lin»* (mm 

I' >:-ULu to 

u A juiddlti 



anil lowur thinU of Un» from 
|HMUiriiir iliac ajiinii lu tuliur 
ui'hii. 

Holil of natci. 

Lowur bonhir of gluteu* m\umvu. 



114 



THE THIGU. 



cti-'t nf the ilium, aad dwold be tikomigiilj manipajated 

iifi n liiiioti U) tlie nppCT bofder of Ike pdrb ad ntmniiidiiifr ptnti 

luuy Ix- cle.arly appreewted duing Uie novmicnte or tli«- '' ' 'I 

the twii riilej of the hoir alitmld be comp t t d if any m<'i 

alx'iit the hip i» iiifpeeted. 

Tli<: fiomtionji of the glutml and ttiatlc mttU where thej escape 
from till- pelvi« iiiay be found bv •Irawioi^ two lines fr<)m ihf 
pimt^riiir ><(i|i«rii>r i1ia>; syxav U> the top of the posterior Ijonleruf 
tlic (fri'Jit troch»iit«-r and to the tobex ischii respectively. The 
ulut4!ul urtery will be foand at the junction of the apjier and mid 
thit>lit of the first, and the sciatic ortent' at the junction of 
luiiUlli; and lower thinU of the second (Fig. 52). 

An important dingnoxtic sign of a healthy rondition of the oei 




uf tlio futuur iii, that when the linib is rotated the tr 
iliworibeii |Nirt of the arc of a circle of ubout 2 inches radius. Wheh 
lUi ini|iiict<-(l fructnre or absorption of the neck of the femur ha» 
liikcn pliui', the ftrc is niiah isnialK-r anil the ninvcment less coin- 
I'lete. 'J'lic liead of the femur may Ix- felt lichinJ the trochanter 
when tile linili ii« rotated inwanis, and in a very tliin subject it but 
U' dftrctfd in fiimt when the finger U thrust deojdy into Scar]i«'i 
triangle. The great sciatic nerve lies midway iH'tween the great 
triH'hiinter ami the iiichial tuberosity, and to the inner side dI' th 
a(«t4ibu1ar iuai>^n. 



Fif. All —A U, Nt'lnlon't tmt line; A C D, Brj'ant'* ilio>feiiiaral trisagl^l 




Vig. H. — l)ai(rruii illurt n iti n j! noMtion of eoumm, sismoiil 6cxure, lUaa 
veau*U, itnil hip juiiit (W. A.)- 



I. Poifit .irMruri^ation of oorbi. 
•i. Po«iT loitl flnxiirv in line 

t: 'H to unUrior •ii- 



t- 



:IU!, 

IITI. 

' juiiit at 1 distjiiio5 



at an inch in a liii« at right 
aiigtvs to raiil'lla uf Huupart'ii 
liT^mont. 
I.inc of (ixternol and common iliac 
art4<ntti rmwiiuj^ lutddlt; of ilntliHl 



line. 



1 % 




angles to the inuldle of Ponpart*^ lignmcnt. 
bf this line corresjioiiilti to the bead of tlit 
eluw till' miildlv of the liotvlrr of the oee- 

|/»Tnur, the aildurtar luhmlt above the ill 
ntflla nro to be examined, anil it should W 
I jinrt of tlie articular enil of the ft-niur u 
^llii whvn the knru is flexed, while during 
If the articular turface of the patella is almvr 
^ The ligamtnttini jKitrUa aud it* altach- 
\o be noticed, and the linger should b« ra 
ins surface of the tibia, down to the 
n is leailily felt behind and below the onb 
^ The band carried to the buck of the joii 
ter iin<l inner luniiHtriiKjii altju'hed to the fiVni| 
jrhen the knee is flexed tnay sink into the 
e joint. The rxtrmal jtojililml iifrrr lied on 
pa tendon and then ).)aii8e8 behind the bead ( 
mni] tlie neck, where it bifurcates. The loTi 
■ubcutaneoiiH and terminates in the proniiiicn 
hind which the jieronatl ttndnn* can I* fel 
Be iiinn' miillfoint lies anterior to and highc 
k>id behind its border will be felt the lat] 
I ponlicin, external to which is the tendon 
lorum. In the living subject the pulsation i 
jtery nmy usually be felt ininiedicitely extcr 
hiiihi ArhiUit niuy be traced to the os calck 
\» a little above the bone, 
.moved freely, and it will be found that tl( 
lotion is greatest when the toe is thtirT>\igh]^ 
^ot take place at the nnkle joint but nininly Y 
JBd by the astnigalus with the calcaneam i 
I 

flowing points of practical utility ifhonld 
i Firstly, on the inner side, but not easily) 
J state, is the bend of the mtriDinhit, aW>tit a 
f the anterior bonier of tlie malleolus ; in front 
jlice of the tulieiosity of the scuphoiil bone, to 
the tibiali.i ]K>sticus may be tmced, and whifl] 
I's amputation of the foot ; and more anteriori 
Bience of the inlmml cuneiform bone, with 
Irtal bone in front of it, and the tendon of I 
Id to both bones. Secondly, on the outer aid 




FRONT OF THE TUIOH. 



the t<<nil<>u8 of tbv i<«rom-i cruiwin^ the calcuu«iim, iind (hrther forwanis 
Uie iiroiiiiiR-ut bikic of the fijth nuUilart<U Uoik, whicli with the litiae 
of the lirrt incUttnrvnl l)o»ie in<licuU-!< tht line of Hcy'ii ojitTttlioju 
The tori ore commonly niuoh (li«torteJ owing to the lon({ pivssuru 
of ill-fitling *luM>, and tin- nii'tiitiiin<>-]ilmlanijt.-nl nrtirnlutiun uf tint 
greut Um: fiujiiviitly i>ii'ji"tt8 iiiwaiiU ami if covered by an ciiUrgixl 
butM (bunion). 



Thk FaiJSiT OF THB Thiuh. 

[All inci«iuu 1h to bt- nia<lf alonj? Pouiwrt'it lijjanipnt, nnii larrietl 
>wn the iniii-r boriK-r of the \\\\^\i for half iti length, iind this iii 
In Ik) juinvd l>y iinothri' acix»w< tin- liuib at Ihikt |HiJnt ; tho tiap of 
ftkin thuH mnrki-d out is to lie carefully ri'Hwtnil to tlu- outi-r xidu of 
the thigh. Thr «U|H;rtirial fa.<cia is to be tint cxamininLJ 

The Super lUM fate ill of thr llil}{li is continuou!! with the iiu|ittr- 
cial fiucia of the abdomen over lV>up.irt'« li;,'ament, and Kenernlly 
ntoino a good <li':il of fat, ]iarticnhirly in thi^ feniule subject. It 
I divixilih- into two iHycm iu the up|>er [^iit of tlni thigh, and the 
de«;ii layer will 1k< kwii by rertrcting the xuiivrticial layer in the 
Mtme way as the akin, but not »o far dowu, the Heparutiou b<.<tween 
tile two layers of fiwcia Iwiiig luurkwl by tome «mull vesjtelii, glauiU, 
Mid minute nerveji. 

The Superficial Vesaels (Kig. 55) aru bnutcbcit of the common 
fHnora] artery, with their mxompanying veiuH and lymphaticx, 
And »m tlirtje in nuniUT, vix. ; — 

, which aris4'« from the femoral 
I'^ut, and piuwea upwapU and 
iuuai ' titiul ol tile itUIuuien. 

Tli' ■</ circumjle.c i7««- tirtirn (il), « Muall bntiich ruiiniug 

|ltwani« a Utile below I'oupart's li^juiiieul. 
Tlie SujKcwr titernal- fiiiAlk urtrri/ (/), running inwarda over the 

natic eord to the scrotum, or to the laliiuiii in the Teniale. 
The l'>iH« corrcxpiind in rour«e, and will \n: itevn to open into the 
lony miplttiiiuu tfin, Tlii» largo vejxul, which commences at the inuur 
iile of an arch on the dorxtiiii of the foot, pastes iu front of the 
iiicr mullroliiit and up into the thigh along the Wck of the inner 
llle of the knee. Aft«r rrteiviug brunchiM from the front uud back 
Uie limb a« well u> thoie jail referred to, it gotut through the 
ml pir.rcdi the sheuth of the vca^'U to open into 
\ eiii. 
Til' 'I' !//(iii<ti will uUo be found betwoen the 

jfcn- 1. and ore arraiij^'ed in two rown, one «\- 



118 



FRONT OK THE THIGH. 



tending obliquely aUiug the groin, and receiving the lymphiiti 
the penis, scrutuin, perinaeum, anal region, nates, and abdnt 




Fig. fi6.- Superficial disacotion of the inguinil and femoral region* (tn 
Wood). 

/. Superior exlrmnl pudic arttfj 

</. I'ouiuirt'n lipiinint. 

/'. luUT-coluiiwiar f^uk'in. 

i. Kxtenitil nbdotuuiut ring. 
Arcifonii or intcr-culumnar 

of extoniul oblique. 
Iiitcmal f*iip|jfnr>uo vein, 
Kc'iiioral lyniphntic glandn, 
Ilin-inguiiial nerve. , 

Snphenoiu opening. 



FEMOKAL HKHMA. 



119 



ill U'low ihc iimliiliciis ; luid auotbcT ntuuiiiK down vertically 
ilow the ^riiin mi'l ilrainitijt the suiJtirficinl lynij)haticii of tin' liinl>. 
be rvlittiiin of ilie lyiii|ilintK'!) to iLt-iw glumlii in lo W lionn' in 
liml, dine* the |)o«ilion uf u Imlx) will vniy acconlinx lo tb'! part 
iuiarily aHcvtctl. 

A few I'trper lymjthatie gliiiiiU will l>e nftcrwanU met with lur- 

ixling the fcmorni reuti'lf.. These (train the tlnep xtnirturoi of 

lower extremity 

The Sujirrficuil Xm'n are tin? t«nuinntion» of the ilin-infjuinal, 

runil bruiii'A of the ijrnitiy-rruriil, and eslrmnl odnnnm*, frtiiu tbo 

linnbAT plexuii ; and tlie fnuUlU and iiUsnial niUinmuf hniicht* of 

the aulcriur cruntl. Their diifLribution will be given luti-r. 

The Dtrp layer of mfiertieial fatin \* more mcmliranoiH than llie 

«n]H-r<icial layer, and will lie licst »ren by raising it fnmj the deep 

fascia Wiientb, lieginning aliont four ini'hex lielow the xniin ami 

!iny it on to Ponpiirl'" liii;anieiit. Thin layer of MU]MTHcial 

will be found to lie Ixiunil down to the fa«cia lata liebiw 

roii{Mirt'K li^anieut, and around the margin of the opening tliniu^'b 

which the Niphenou.-i vein iliBappeaw, calie<l the )\ii\ihrniiu» opfiiiuij. 

Hjtilike the fU|H'rlicial layer, it doe» not piuw over I'oiipart'it li;;n- 

^tafiit, and then-furv )iaj< some influence in diriH'.ting a large fenmral 

Hentin alon^ the groin. It receive!- tin- name of I'rilirifnrm futcin at 

Bii* luurt when' it cnMurni the xapheuoux oi>ening, becnuxe it in |icrfo- 

^kled by noineronti email aperluruH for the pnxta^e of vetiudx ami 

|^nl]<hatic<^ Great can* niuxl lx> taken not to destroy the >i«i>henouH 

Bf("'i)in({ in removing the deep layer of the nuperlicial faw.'ia. 

B The Iirrp/dtcia of tht ihujh (fiiBcin lata) i» now e.xp'jKed, and in to 

He cleaiK-<l lu far as '\» uucejsitary for the ^tudy of the parts concerned 

Ml femoral heniia, the wvrrul n<T\-iM piercing it being left for mil>- 

K<|Uent examination. 

H Fkmurai. Hkb.ma.. 

H [Tlie MpbenniiK Vein ix seen til dii4ipr>eitr tliriin;:h an op4'nin^ in the 
Hb»cia lata nljout on inch and a hall heluw Pi lU part '.4 ligament. This 
B» the saphenoUK opening, which '\» oh.scured by the ullachment of a 
^Diirtiou of the itU[H-rlicial fuMcia, culled (mm the nutiieroiix peil'orationit 
Hb il cribriform. If the cribiiliTiu liutcia have lieeli caiefully rem<'fed 
Hi>get'ier with the ouiall veuiH, the artihcially pro<lucud »iphenou8 
KjK-uing will be clearly MmD.] 

H The SaphenouB opening (Kig. &3, o) varies cousidenibly in 
HjUffeivnt (tubjecU, and xa generally I>u8t tieen in the female. It in an 
Bbval cleft Dearly half an inch wide, without any di^ttinct limituliou 
Hiitcrually, but sharply bounded on the outer side and Ih;1ow by the 



FEMOKAL HERNIA. 



wjniicircular bonier {fidcifonii inuri/irt) of a process of fascia 
(jrroctu of Burnt), whii'h jioBsea from the fustiu Lita of the front of 
the Uiigli to l)ecomt: ntl^ichtHl to tlie whole lenglb of Ponj«xt'« 
ligament. The falcifonii margin whicli partly enciruleA Ibo long 
saphenous vein hns a well <Ieiiue<l cur%'e like that of a French hum. It 
cnisses iu frunt of the femoral sheath to joiu the inner port of PonpiiitV 
ligauK-iit lit a. variable point, while internally and below it jjoscs 
im^iereeptibly into the pubic portion of the fascia laUi which 
covers the jiectiiieus muscle. The pectineal fascia passi:'S behiiiii 
the femoral fheuth to lie attachcil to the ilio-pectinenl line abiivc, 
and to beitonie continuuu.s with the ilio-jisons fa.«cia extemnllv. 
The Riijiheiious opening is the exteriml aperture thrtmgh which 
a feni(Jiiil hernia jxis-se.-!, and might tlieivfore well be calleil thr 
external femoral ring, although strictly speaking there is in the 
undi»)tected condition no delinite ring, but merely u weuk point iu 
the fascia through which the heniia protrudes, pushing before it 
the cribriform fiu<cin. The edges of the saphenous o]>cniiig will be 
found to be relaxed when the thigh is Hexed and adductr<l, thr 
position in which the limb is ]ilaced when the " taxis '' i.* applied 
for the redaction of n herniiu 



i 



[An inuisiou is to be made from the lower end of the saphenous | 
opening transversely outwiinU for two inches, and a corres|ionding I 
one immediately beluw PimiNirt's ligament, and the piece of foiKia] 
thus marked out and iticludjjig the I'alcilbnn process is to l>e ivflectwl j 
to the outer Kiile.] 

GimbtTiiui'* liyuiiimt (Fig. 68, It) consists of a i-trong band of 1 
fibres passing from the imiermost jiortion of Poujuirt's li^^nient to] 
the inner exti-emity of the ilio-pectineal line. It fills the onglej 
between Poup.irt's ligament and the ])ubic bone, and present* a ft«*| 
edge turned outHaiil.s towa^d^^ the femurul sheath, ndiiiid it Ui<l 
the conjoined tendon, the fascia traiiaversiilis, a small uiia.stoniotiej 
arch between the puUic branihesuf the deep epigastric and nbtiinitorl 
ve«»eh<, and mnix- deeply the subjieritoiieal li.ssue and |>eriloueUDiJ 
The name Liguvn-iit of Vooprr is given to a fibrous baud which rtintj 
along the ilio-pectineal line from the ilio-pectineal eminence to I 
pubic spine. 

The Sheath of the Common Femoral Vessels (Fig. 56, ky 
lies between the j)roi'ess of fascia lata (proies.< of Uiirns) passing tol 
Poupart's ligament iji front, and the ])cctineal and iliac fasciMrl 
behind. This sheath ajiiipaiu as a tube, brooder al>ove than below, f 
and composed of a ilelicute connective tissue, containing more orl 
less fat. It iuvest« Uie femoral art en', vein, uud a portiuu of 




THE FEMORAL SHEATH. 



121 



Jeep lymphatics, and may lie tmceil bcneatli Poiijjart's ligament 
upon Uie external iliuc vcswols, where it is continuous with the 
sub(i<Tiloneal fascia which ensheaths the latter, while lielnw it may 
le WWfd B!i a vascular sheath thrcmghout tin- litiib. It is usually 
»Ut«l to be formed by tlie union of the fascia transversnlis and 
(mo* itiua around the vcsstds, hut it is essentially n jjioloufjiition 

Fig. S6. 




,. y 



"' "It Jillijieritoncal tissue sheath of the iliuc \t'tw»;ls, reinforced by 
"""le 6br(a< from the fascia Iransversalis in front, and is sejiamted from 
j"' iliac faiM:ia behind by loose connective tissue. Three vertical 
"raiiotui, one in the centre and one at each aiile of the tubular 
"'"»tli, will enable the dissector to see that it is divided by 
'*» tleoder iiepta iiito three compartments, the femoral artery 



Fig. 06. — Crural •hunth l.iiiJ njien (from Wood). 

I'' Uiddl« rutanrous n^r^•c. /. Mnritin of snplieiious upt'niiig 

^ CUtNl to inorr sidrof Gimbvmiit't (tunvsd tinrk). 

' liganjenl. k. Fcnioriil «beatlj o[n;iiid by threo 

•■ IlUc portion of fucia lata. iiHisions. 

'- Pubii portion of fuicia UtA. /. Saptienoua vpin. 





FEMORAL HERNIA. 



occupying the outermost, the femoral vein the middle, «nd sub- 
peritoneal fat and a lymphatic gland the innermost or smallesl 

line.* Thi» last division of ths; 
Fig- *7. femoral sheath is the finnen«l or 

rriiral ciinal. 

The Femoral or Crural Hing 
(Fig. nw, 12). — If the linger Ih- 
pajised upwards along the cntral 
oanui, it will enter the < 'rural or 
Ffiiiiiriil Ri}ig heueatb Poujiart'* 
ligament, difiplucing 11 Ijinphntic 
gland and a small piece of snh- 
[leritonenl fat, which occupy it, the 
latter fonuing the tcpttim crvmk. 
The lioimilaries* of the crutal ring 
can W Iwlter felt than seen, and 
are, ih /nml, Pouimrt's ligament, 
with occasionally a dLslinct hand 
of fM«'ia tninsvereali.-! beneath it, calleil the ili'tp crfiTdl nrth ; 
Mniiil, the b(xly of the jmlies, with the pecliiicus muscle and 
pubic portion of the fascia lata ; cMrninUy, the femoml vein ; and 
internaUij, the sii.up nmrgin of (iiml>erual'a ligament. The cruml 
ring is the aperture through which a femoral hernia leaves the 
abdomen, and the pnint at which .strangulation mcst commonly 
occurs ; the tiuger shmilit therefore thoroughly explore it. 

The Crural or Femoral Canal (Fig. 56) is the canal, half •■> 
inch in length, along which femoral hernia detcend* fi-om the crural 
ring to the saphenous opening ; but us soou as the hernia has forced 
its way through iJiat sj'Ol, it atctrnd*, owing to the clos»- attachment 
of the Kujx-rficial fascia to the margin of the sapheiioua opening,! 




I 



Fig. 57. — DiaframniBtic section of cniral cansl (W. A.). (Section internal 
to that in Fig. 38.) 



I. Abdoiniunl muaclea. 

'1. Prooew of faAciit tiiintiVorMilis 

utrenrthcning front ol fciuoral 

aliralfa. 

3. Kasoia Iraixvcrxtli*. 

4. Lytophatic glnntl. 

0, 6. Suuperituuenl tissue. 
7. Peritonruni. 



H. Obturator fiuoia. 
H. Poupiirt'it li)iHment. 

10. Ubtunitor iiiiLTQu.-!. 

11. Kalt'iform proccM of Bums. 

12. Tubic bone. 

13. Crihrifonn fawin. 

15. I'ubic portion of iiucia lata. 
17. I'rctineuii. 



5?^ 



• A precisely siiuilur uiTungement i« found in runnection with tlin ilia 
vcwela above l'oU|Mirt'« li^ninont (ht " Journal of .iiiatoBiv and l'hy-inlo»T,"j 
1891). t. - '^■ 



OOVKRINOS or PKMOKAL HERNIA. 



12.} 



and lien nlong Poupart't ligHnieiit, or if of Urge size, mAv vtnu-h 
the fancia sulDcicntly to mount over tlie liipiment and liniuktu au 

juinal he niiit. 

The Co-veringa of a Femoral Hernia (Kig. S7) will be mulily 



«». 68. 



j»WJt»i 







if the roiirxc it tnki-« hiu Wi-n ihuroughly uiiilot»to(xl. In 
doKsent tlic inti^tiiiv jiUkIic* lieforc it (1) peritoni'td tittc., (2) 
k1>-]ieriU>nefll fat, (3) fviiioi-Hl hLouUi, (4) cril)rif»rm fii«cii», (ft) sujxt- 
W laeda itnil akin. It muol not be 8U]ip<Me(l thut tin- Murgt'iiii 
recrigniM' iLi-te variutm cuveriuKx in o|)vruting upon a atraniju- 



. M. — Swtluu of the rtrueturcn which dom beneath the fniiural wrh (from 
WiLmi). 



foUIUUt'* liKalucul. 
I 2. Iiinr jinrtinn nf the frtftcitt IntA. 



4. Pu! 



:u Ur 


10. 


-:<). 


11. 




12. 


. - -if 


13. 


>.»'U 111 


11. 



•hcAlti uf Uia trniuiul 
Ita uul«r l*onl*fr iil n, wImtc it 
diridn into two \M\rta ; unc it 
i-uotiuuutu with thu HlieHth »f 



the jMuiw (U) untl iliiu-ut (7^ : 
the nttuT OS) t* Inxl upon tiiu 
cu|i>uU' uf the hl|i-joint (&) It 
ta uttiii hfU uIkivd to liin ilii>- 
pi-ctinual line. 
10. Till- untiiriur orurnl nerve. 

IJiinlwnwt'i lijpiineiit. 

The foniornl rinj, within ihi' 
feiiiontl dhealh. 

Femoral vein. 

Kvinoral artf ry ; the two vcjuh-I* 
■nil the ring are lurrouiiilnl by 
the feniorul «beuth. 





FEMORAL HERNIA, 



Inted femoral hernia, but it ih necessary that he should tdentif}- the I 
or peritoneum, which is usually to Ije recognised by it« thin bio 

Fig. 69. 




Fig. o9.— Diagrammatic section through femorat uid iliac dieatlis (AV. A.). 




1. Extrmul iibtlomiiial fiu«ia. 

2. Fmu. 

3. Abdominal muuln. 

4. Peonii fnscin. 

6, 12. Fnwiii transrcraaU*. 

6. Anterior cninti nerve. 

7. 11. Subperitoneal tiwue. 

8. Iliac fatuin. 

9. reritnncum. 

10. Mus'les of jKist-abiloniinnl wuU. 
lU. I'oupart'f ligament. 
14. Crest of ilium. 



Id. 



18. 

17. 
18. 
I'J. 
21. 
23. 
2-5. 
27. 
29. 



Proeest of fascia IransTenolit 
strvnKtbcoing front of femoral 
tbeath. 

niaciis. 

Femoml nrtery. 

Musi les uf gluteal region. 

Anterior villi of femoral sheatl 

Deep layer »f superfit'iul fu 

Septum of femoral sheath. 

Feinural vein. 

Xeck of femur. 

Faooia lata. 



FEMORAL HERNIA. 



125 



9[iM>tnee, itml \.>y the tliiiil geiierully to be seen through iU nliglitly 
iniupMait wall.* 

Surgery. — Operation fur ulranijulitled femoral heniin. The point 
''f Kiriitiiiv iJ very rarely nt the sn|ihenou8 ojieiiing, sime it l«'Cotnf« 
»miich fiiliirKe>l in an oM hernia iw to offer no re«isUmci'. The skin 
inJ Hiperfirial structures haviuj; been Jiviileil (nsunlly l>,v a vertic;il 
indaonX ^^^ forefinger can therefore Ik? reiuJily pii.s»«l along the 



Fig.flO. 



Kig. 01 . 





c 

^JHRlXutl en the inner side »( the herniu lo the crural rin^, wheiv 
^^'•Sfictiire will be found. This nmy V« most salisfnctorily and 
"f'lj' rt'lirve<l by cutting cjiutiouslv inwards with a hfrnia-kiiife, so 
"•''Uoti'h or divide (linibeniat's ligntiieut ; but if thia i*liuuld not 
I'fvi? (,uftii:iiMit, the wic must lie Ciirefully opentil atul tlic »trictnre 
.divided frotu within it. 

Tile only jossible dnngrr which can be met with in tlie deep 

lO'ioB is an abnormal distribution of ihf olilurator artery 

(Rs*. W) and 61), which, if it arise from the epigastric ivrliTV and 

*ind clone to the innrr i>iile of the neck of the sac, nii;,'ht be 

liivideii and give rise to troublesome hicmorihage. Fortunately 

II )J u»vcnael, if it exist", is sehtom dauui^ed by n cautious use of the 

kA^F, and, as it is impossible to ani-eitntn its presence lN.'f<ireliaiid, 

^^existence may l>e ignored in ]iractici'. 

[The cutaneous nerves of the ujiptr part of the front of the thigh 
IK to Ije examined with the fiutciu liita, iK-fore it is i-enioveil to expose 
Scupa'a triangle.] 



IF 



60<— IireguUr oripn of obturator art<T>' from cniitiistriii. 
(1 in 4) extenul to crural ring (from \Voo<l). 



Ut Turietv 



Fif.Sl. 



-Irregular origin of obturator artery from ppiv'sulrif 
(I io 80) inteninl to cniral ring (fmm Wood). 



2nd rnrietr 



* The (tudi'Ht it (uirticulai Iv wariici! ngaiimt (lio r>ommon error of suppoting 
Jktmmat a hernia to be 11000(11 and gliatenin; on it« rittrior. 




126 



FRONT OF THE THlfiH. 





Fatcia latit of ihitjh. — If tlie process of BiimB pa.<<ging to Poupurfl 
ligament in front of the femoral shentli and anterior cnirul iier\'e ''^^| 
diiscctetl away, tlie trui; an-angi'iiifnt nf tin- deeii fnscia nf the up]*T"^B 
piirt nf tlie thigh will be much more clearly underBtood. It will thtm. 

Fig. 62. 




11 U 



Fig. 62.— Scclinn of thigh through upper jiart of Hunlcr'» cminl (W. A.). 



1, 2. I.ymph iip»i'oi. 

3. Long mphpnou* norrc. 

4. Ruperficial fascia. 

5. Femontl artery, with Mnnll venu' 

eumit«a (femoral vein ileeiKr). 

6. Deep (aaria continued orer back 

of thigh aa nuperlicial hi)'cr of 
deep faaria. 



7. Shenlh of viMcl*. 

8. Middle tuycr of deep faacia. 

9. l.oug Niplleiioua vein. 

10. IJrt'p liiycr of deen faacia (iiiUMa*| 

lur apont'uro.in;. 

11. Great Bciutic nerve. 

12. Vein 



THE FASCIA LATA. 



127 



seen 08 n stront; flbiouii invi-HUiiunt of llie tiiUNcl(<4, aUaclied ttbove 

Mnmul tlip nmiyiiiR of the ]H'lvi», fp>iii llii' uiitvrior ^ujn-rior 

priiie i-xtenially uml in (nuit, aUnn; tlit? oulvr lip of the iliac crent 

jvinx li dftrj> j>rcicc'(w, liowcver, ou the itiluT surface of the tenitor 

mxiuD femoris au>l j^luteiiit uiuximuM), to the |K><iterior superior and 

kferior iliiir «piiies nnd the inlervrtiiiig iiotcli, tu the greater uiero- 




■ 


I ^^ 


—*= 


=rT 


=r— 1 1 1 


i 


M n 


in 


U III 
of til 


14 11 10 1 


Fir. «3.- 


-Uorixoiital MK-liuii 


Kh at li'vrl lit hl|i (alter liraun*). 


. F«l. 








15. Artiouliir vrMcl*. | 


^ Bnrtoriii- 








IB. Hn'itt wiuliii nerrc. 1 
17. Frmnral vi*in. ' 


. !•• ' 








. 01 


:^illu 


18. -iO. Si'intir rr«rU. 


. A.I 


1.. 






1». Pmhis. 


. T- 


feniorit. 






'21. Fi'moml urtiT). 


. A 


■II*. 






'J2. Iwhiutn with obtUfHtor interniw 


. (ii 


.«. 






ttiiidiiiK uniutiil tt. 


. (11 


taut. 






'J.i. Antirior i riiml inrve. 


». An...- •■;; 


u«. 






24. (rri'iit aiuri)-« iiitic llRiimcnt. 


. Pertinruik. 








SA. H(*nil of ft.innr. 


. GliiteuB tnaxiinu*. 






•27. IliiU'U4 (trillion of rectus butwrvii 


. Obturator. 








it Niid acetiiljuluni). 


. Pjrrifiimiiii 


tiimi.iii. 









128 



FRONT OF THE THIGH. 



sciatic liganii'itt, the oiit«r li]i of the tuber ischii, the outei* boj 
the ischiopuljic rjimi, the iiiai>;in of the syiiiiihytii-s, the piibic hd; 
crest and epine, ninl ovi-r the p«-ctineiis to the ilio-pectineal lin>\ 
the iho-jiectiueul eiiiiiieiice it bccoinus lUrectly coiilimi>>ns with 
ilio-jwoas fftsciii, which nmy be Inllowetl uji over the ]isou;$iin'l iliu( 
tf) the lumbar verlebiie iiml inner lip of tlie iliac crust. Tht fa; 
covers tlie whole of the limb, seniling fieptiil processes l)etween 
muscles aiul to the bony ridges from which they nrise. Tl 
common I'enionil vessels, with the iinterior crural nerve, lie outsii 
this investnientT although they are concealed by the accessory pi 
cess pu^sin^; <rom it to Poupiirt's ligament ; and two lar^e apertu 
will be found in the fascial sheath, one for the deep femonil ve.H.se' 
oppfisite the lower liorder of the pectiiu-us, and another for 
superficial femoiiil vessels and n ]>ortion.of the anterior crural nei 
at the i>i>iiit where the sartorius crosses the outer lM>rder of 
mlductor longus, Besides these there are smaller aperttires U 
other ve.-jsels and nerves. 

In the middle and lower portion of the thigh the fascia 
sends inwanls two strong intennuiieular septa, an exteninl 
dividing the vastus externus from the hamstrings and an internal, 
l)etween the vastus intcnms and tin- adihictors, both giving attach- 
ment extennively to muscular tibres (Fig. 02). The portion of 
fascia lata on the outer side of the thigh is of reniarkaV)l<- strengtl 
it receives above the insertions of the tensor vaginuj feraoris 
gluteus niaximiis, both of which it encloses before reaching 
attacliment to the os innoniiiuitum, and rutis downwards to 
attached to the outer border of the jaitelhi below the vos' 
externus, to the ligamentiiiti patelUe nml to the outer tuberoail 
of the tibia. It is sometimes called the iUo-tiltiid Imml. 

The hamstrings are bound tlowii by a layer of fascia within the 
fascia lata, and in addition a thinl and still deeper investment can 
be demonstrated as a sheath for each of the muscles (semimemb; 
BUS, semitendinosus and biceps) (Fig. t)2). 

Cutaneous nerves (Fig. 64). — The Ilio-ivyulnal nervf, which 
emerges from the external abdominal ring, in its couree to 
scrotum or labium gives one or two small branches to the thigh. 

The Crural firauch of Ihr Ijfiiito-crural nrrve pierces the fi 
half an inch below Pnuparl's ligament and just outsiile the femoi 
artery, and joins the midille cutaneous nerve. It is Very sell 
satisfactorily seen unless traced from the lumbar plexus. 

The Exttrnnl cutaneous uerre (3) is to l)e found amongst some ft 
in a fold of fascia lata close to the anterior superior spine of 
iliutu, and piciccs the fascia at a voi-iable point, to be distribu 



t ca^i 



Sl'AKI'A S TKIAXfiI.E. 



12.'» 



.\ 



BiiU'rior otiil II jiofUfrior bmndi to the uuter aide of tbu tbigli 
irt iif ilu- buttock. 
MiddU f^taneous nerve 15) (from tlie unturior cruml/, pierc«vi 
:ia in the upju-r thinl of the thigh, iistiully in two ploiuai, 
11 be ttflerwania tniccd n* far as the knc«. Thin nciva, or 
jKT broncli, umially jiicrecs the «ftrtoriii>i, whirh riiimclo it 
]y iiup|ilir». '' 

Intrruiil nitantfuu and l^nu) Suvfutiioiu nervet nrv nut neen •t J? V^t 

Soahi'a'i* Tuianoi.k. / V 

faxci.i in 1" lie reinovtMl from the hollow In-low I'oiijjurt '»'''"' ** 
t, and IroMi lUv front of the Ihi^h un fur un the akin hax 
•rtiTtiHi, and tin- niii»<li-H. vc»-M-I», ami ihtvcd lhn» txpoird 
!«■ HO thoniiijihly cli'micd a« i» |»<i«i>>il)k' without tlinturliiiii' 
tlationa. Thi- cutaiiuniiA ncrveit arv nUo t» ivmnin uiitoiirhed.j 

pii'< trianifU is u BUiwrHcial Hpacv in thf upprr thinl of thi> 
r llie thigh, I'ontiiiniti^ thr fi^inorol vciwelii nnd lUitt-ririr I'.rnrnI 
The fcri*- of till! trinn^li! io formed by roiijuutV lignincut ; 
liondtT by the inner edgn of the wirtoriuH diuw:K> ; thw •iiniT 1 
Bn|bo out«r margin of thti mUhu'tor longuo ; ami thv ajirr by 
^PBg of thviMf uiUHi'lu*. The MiHiue in covered in by till- itkiii' 
l^ruciAl fttticiH and Hnniti'ii proci>«» of the fuxciu lulu, and it" 
II now 1* ai-vu Ut \iv formed by the psMHU and iliucna on tlii- 
(de : tlie pcutinvuM and, in M)iMr subjects, a xmall poitiu 
•ddactor bn-\'is on llie intifr side : tliwu miiMles all Ipim^ 

by their foxiiD. 
[iu'« trianglo cmitninii the common fcmornl nrtcry giving off 
nil bnincheN nn>l bifiircnting into the 8n{)«rliciAl and deepdivi- 
thi< feuiorul win with it« triliittarim iiml >tomc dee|i lymphatic 
and the aniurior rrural nerve with Hume of it« brunchoK. 
ihenous vein is not one of the contents of the npuce, nntil it 
■ail tlio foai m lulu to end in the common femoral vein. 
Femoral Artery In Scarpa's Triangle (Fig. f!4, 4). — 
tii<ii.il ailcry (umler wliirli tiiin is inrhnleil the common 
trunk and lt> «u|H'iti<:i;i| I'l inorat Imtuib) is the continuation 
Ibktdniid iliai- int>-re. in.l ixli-ndi- fiom I'oilpiut'" liguiuenl t» 
in the u^l iuw, thndigh which it jWHMes to the 

Tlic v expoKed i» that aliove the point 

^ f|K Mrtorius, ami i* nsuitlly over u thinl of the whole 
iSilircMtd. When tlie thigh is slightly Hexed and abducted, 
y runs from a jioint miilway b<;tweeji the nymiihynift pnlii* 
anterior ouperior iliac «pine 'or about a thinl of an inch to 

K. 



130 



SCARPA'S TRIANOLK 



the inner side of the centre of Poupurt'a ligament), tlirongh 
middle of the triangle in aline with the prominent adtlncti'F tMl>c«i 
on the inner condyle of the femnr ; bnt when the thigh is ftt 
extended it will l>e seen to wind slightly to the inner side of 
linili. This portion of the arterj' lying within it^ .shentli is coti 
by the 6uj)erficial fascia and the fascia of Burns, and one or two 

bj-anclies of the internal cu- 



Fig. 64. 



1 i^^, \ 



taneous nerve cross the vessel 
ut variable points. Beiund 
artery from above down 
are, the jisous ; the nerve 
pectineus ; the pectineus it«lf, 
separated from the femoral artery 
by the profunda aitery and vein 
and the femoral vein ; and 
fjisionally between the pectini 
and the adductor lungus, a $mal 
[lortion of the addnctor brcvu. 
To the outer side throughont u 
the anterior crural ner\-e, usually 
sejiarated at the upper part by 
n small intei'spacc ; and the long 
saphenous branch and the nett* 
to the vastus intern us &re in ei 



to va^\ 

lelf. 
:ery 
ein 

11 



Fig 



10. 

11. 

12. 

13. 
14. 

16. 



64. — Supcrficinl iliMOction of t 
front of the thii;h (from Ilin 
feld and Levcillr). 

Poupiirt's ligament. 
Suptrticial branches of fun 

arti'ry. 
Exlomnl rutancoui nerre. 
Femoral artery. 
.>, a. Miil(IIi> cutuneouB nerro. 
Femonil vein. 

7, 7. -interior dirlidon of intenut 
cutaneous nene. 

8, 8. Posterior div-ition of iDtenul 
oulaneoui lUTve. 

llnimli to >art)riu9 front 

iiitaneoua. 
Saphenous rein. 
Sartoriua. 
Cutaneous branch of obtuntor 

ntTVf. 
PIpxus patellic. 
Patellar brunch of Ion; saphMiotti 

nerve. 
Long or internal saphenous nerrc. 



"1 



THE FRMORAL ARTEKY. 



131 



ation Willi it at the lower part of the npnro (Fig. Of), 19), th« 
latter eitcniul to the former. T)w fi'inornl vein i* Ui the inner »iil« 
near Poujiort's 1i;;iiinent, but lower ilown p<u>«e» liehiml the artery, 
and furms one of its pooterior roIation8 at the ap«x of the irioiiKle. 

Surgery. — From its miHTficiiil piifiitioii the f<;morol artvrjr outi l>e 
i-eaililj Iclt durini,' life, and cnniiirvraioii may lie offecteif in iiiiy 
part of the trinu>!le, Imt iiio.-t Riitisfnr.t<prily n^nit tlie niitr(;iu of 
the puliio iKine. The artery hiis iH-nii tied alxivi? the ori;;iii of the 
~~ Dfuoda, through an in>;iiiiuti imnilh'I to PoajMirt's li|;ameiit ami half 
inch l>elow it, liiit the vensel in mure i;omiiioiily liedjiixt ln-l.iw the 
pniut at whirli it in iTosscd by the inm-r •■■It'i' of tin 
The lotter ojH-nition ia readily performed through an iii< 1 

tlini- til four inches long, beginning two inchcn ImiIuw I'oinjaita 
li^uiiient and running in the middle of the lower part of the >|wic(<, 
ad in Iheaxii of the aliUucted limb. The inciKionmhould liccarrird 
once thmU'^li tlie fiMciu «o at U) expose the fibres of the .'uirtoriux, 
[lich are r(cogni"abl«' by their oliliijue direction. The niuncle being 
Bniwi a little oulwnnlx, the fibroin* tihenth of thi' vegscU will be teen, 
t(i mu»t lie airefully o|i«ned with the scalpel, when the mtery can 
I inalatetl and Becured. The needle may be parsed from lither side, 
lieiiig taken nut to pierce or include the vein, which i* 
'. in very done couluci, or the long saphnnouB nerve which 
iti'r side of the veiiM>l. 
When the femoral artery is tied aliove the profunda, the circidulion 
_ij» carried on by the obturator, gluteal, and sciatic aiti-rieM, wbiidi 
Atomose witn the circumllex and perforating bmnclie« of the 
ofandiL, aiul thus indirectly with the articular branchca of the 
;>Uteal. The ujieratiun i» not a denirable one on account of the 
II interval often exinling between the origitix of the ileep circuin- 
iliac an<l •■pignetric ves^'U and that of the profunda. 
When tlie uilery 13 tie<l Ix-low the profunda the cin^ulatiun i* 
ried on dinclly thi' ' ' lunication of the terminul branch 

f the profunda with ' i/ui</ii« ami the braiiclieo uf the 

Dplitral, in addition tu ui'<- - ^oi^Muinoaea given above. 

Branohea la Bo&rpa'a Triangle (Fig. (14). — The araall (1) 
amrJicMt ryiijimlnf , (2) tuiirrfiriiil i-irramflr.r. iliac: and (3) tnperfieiiil 
'■ piuUc, have been alremly examined. A larger brnnch (4) the 
atmuil ytuiie, arweg from the up|)er part of the nrti;ry and 
I Ixineath the hucia lata to the scrotum or labium and )H'rimi<um. 
^11 many subject* the detyi ijnijuitrie and ticcp cininiiflrj tliiu 
tnanehca are teen to uri»e below roupart 'a ligament from the common 
nonl. iiustead of from the external iliac. 

The largest branch, (ft) the •firnfitnilx artery, arises from one to 

\-i inches or more helow Puupart's lig.iinent and is now seen lying 

to the outer side of, and then hekiud, the femoral ailcry tmOi 

K 2 



132 



SCARPA'S TKIAXGLE. 



vein, ond resting upon the iliaciis and jitctiiic'us. Should, ho« 
the external circurallex arise from tht< couuiion feniorul ingleidij 
from tile profunda, the cojumencement of the latter vessel 
beliijid or even to the inner side of the superficial fcinoml. 
profiuidu is the grcBt ortery to the muscles of the thigh, and will I 
afterwanls dinsected. 

The Femoral Vein nt the lower jmrt of Scarpa's trtanjrlD li 
behind and sometimes a little td the outer side of the artery. It th^ 
crosses olilii|uely behind it, and iifler Vieing joined by the profun 
vein, i-eaihes the inner side of tlie common femoral artery nt 
upl>er part of the sjiace ; and there it receives the saphenous vc 
which has previously l>een joined by the veins correspondin-^ to I 
small branches of the artery (aujierficial epiga.-*tric, circmntlex ilk 
and external i>udic). At the apex of the triangle it i» very cJo 
connected with the artery. 

The Anterior Crural Norve (Fij;. 69, 5) is derived from 
2nd, 3i\l, and -Ith nerves of the lumbar plexus, and enters Sea 
triangle l>eneath Poupart'a ligament, resting upon the mlja 
boi-ders of the psoas and iliacu^i muscles. It breaks up into sup 
ficial and deep divisions, which are sepamted by the external cirvufl 
flex vessel.*!, the tupcrfiruil giving off the middle and internal cutanea 
nerves and sujiplying the Mrtorius ; the ileep .supplying museull 
bnmches to the pectiueus, rectus femoris, crureu.s, vastus intemus iin3 
vastus externus, and tin- long or internal saphenou.H ner\'e, which 
becomes cutaneous at the inner side of the knee. The nerve to the 
pectineus piusses Iteneuth the fenionU sheuth to reach the muscle. 

[The limb being extended, the line of incision on the iuner 1 
of the tliigh is to be pnalonged to three inches below the k^l^•e,( 
then earned across tlie limb, when tlie skin thus marked out is to 1 
reflected to the outer side, and the suiierliiial fascia to the tan 
extent, all the eulaneous nerves being carefully leA at their ]K>inta I 
emergence from the liiscia lata nud traced h> their termination*.] 

The Burm in front of the patella may be tlii'ee in number, (Ijj 
hirui miliciilaHeii, large and jiartiiularly prone to intloinmntion 
peixons whose occuimtion involves much kneeling ; ('2) a bu 
tnhfiucialu beneath the bands of deep fascia im.'s.-'ing in fiont of 
patella ; (3) u hurm tuUenJiiitxxi, small and inconstant, l>eneatL I 
pn)lcmgation of the rectus tendon over the bone. The caviHesI 
1 and i occasionally intercommunicate. 

Piercing the fascia at several jjoinla are the cutaneous nerve 
the thigh, some of which have been already seen, but the folio 
are now to be traced to their distributions and then to their orig 
the fascia being removed as may be necessary for the latter pur 



THE FRONT OF TUK THIGH. 



133 



Tlic IntFmal r.utanfoiu ti*nw (Kig. (i-1, 7, 8) U ft bmiich of the 

anterior cniral, it fjlvtw two or tbnjf Ruiull twigx to ihv upper luul 

iriiu-i parU of the thi);b, uml iTUKaM lUi< fviuoml artery in Scurpa'n 

li i;iii'j)i'. Either before or after iloiii;,' so it diviilcs into two 

"T iiiid }Kjiilcriur. Tlii! unterinr l>rniioh Ixioiiincs 

lower thinl of the thigh, tiin lilnrnt-nt^ reaching u 

Itir <k> lilt: |>(il4;lliir plfxn» ; the jnmlnrinr briuioh iipjH'urii c\o*o to the 

s^phcnoiig vein a little (iljove the knee, fttnl il» bnuirhe^f unite with 

if the otlier branch, with the intenial HiipheM<>u>t nerve, iuhI 

oimlly with » i<U])vrli<:iiil bmuch of the obturator, und iiru 

ilittributwl over und a little beJuw lla* inner udu of the knev. 

The L'jiig or Intrmal Suj^houm n*rvf (Kig, (II, 16) (the conrso of 
tiioh will b« aftvrwanla Keen) Ix.-ojitni** rutaneon* nt the itinnr side 
tl«- knee-joint, where it lic« ut tlr»t in front of tho ajiphenoim 
vein. Ik-foii! lurciniing ciitaiii-oiiK it miuiLi a lai'ge bninoh forward 
I'l the Kkin of tim |wtella {ruiiint nUiDirm jHitdlm) (14) which 
pi' !'•"> tlie BartoriuH, iiud unites with bniiicheH of the intemul und 
iiii<Ullr lUtaiH-oUB und exlemul popliteal nerve* to form wliut luu 
bmi called the ptrjriu iMittlltr. 

Tixr Suprrfii-ial I'riiu of the thi|^h are very variable, but they 
either open into the unphenouu v»!in •eparnluly, or form ono or 
mom iu'|utrui« lirandiiK which ji<in the main trunk at or n«ftr tu 
BUS upuuing. ^ 

MnHCLKs or tiik Froxt or the Thiob. I 

• of the fitNciu lutiiure to lie riMuoved and the cutAneoua 

ide. By Hexing the knee, the niuvles of the Imnl 

■ '' 11 will Ixt iiiiulr ten->e, except the »iirliiriii", which inu»t 

d with hotik* iu iii'dur t>> clean it. All the lo<m>' funcia 

; u, i.iiioved, and euch niuwde cleaned in the iliirc.tioii of its 

li I 1 .-, speiiul cttlx- iieiiig taken to ex pose clearly, lu far as [KJiuiible, the 

uiin'iu and insertion of each.] 

C<>un«ict«v1 with the fascin lata on the outer side of the thigh in 
tho Tensor FoaoieB or Vaginae Femorls (Fig. 60, 4), which i» 

^0 lie expo ' ' ■ ■ ■ ■'..- riwciii below lli if the ilium. 

^rke must; I ide of the ani' : l or »pine of 

^Moili iiMin pill III ilie notch bctwciu iiH.' iwo untcrtpr 

^^^Tcj 11 n Ainall purtiuii of the cn-st, unrl fi-om it« fojiuial 

^^^^^^^1 I -( downwards and buokwnriU to 1m i>ivm-(<»{ 

H|^|^Bk^< iliegp'at trochanter, the fascia being vplit 

^ttt5poInl to reci ivc the muxcular tibrei*. The mUHcle iw ilt 
Hum implies, it; u leuaur of the foiiciu of the thigh, und iWruViy 




134 



THE FRONT OK THE THIGH. 



slip 



supjiorts and assists the other muHcles of the limb, especially the 
gluteuK nuixiinus, by fixing their fascial attachiueiits ; it is also an 
abtlucliir and inttnial rotator of the femur and bcLs upon the trunk 
mIr-u the thigh is fixed. It is mpplied by a branch of the nupe- 
rior gliiteiil nen-e, which may bo seen entering the deep surface of 
the nuiisclu when it is reflected. 

The Sartoiius (Fig. 65, 5) is the longest muscle of the body, 
and when dissected lies loosely upon the subjacent muscles. It 
arifu from the anterior »ui>crior spine of the ilium, from the notch 
below it:,'aHd from the outermost portion of Poupoit'iJli^iment ; 
and crossing obliquely over the thigh, winds behind the inner tuber- 
osity of the femur luid, tuniing fonvaixls below the inner tuberosity 
of the tiliia, U ixijit-f/fi^ into the .lubcutimeoua surXace_j>elflil_lhe 
junction of the head of the bone with the shaft. l>y u broad 
tenilinoiis expansion, which is incori)OTated with the fascia of the 
limb and (iverla])8 tliu iusertions of the gTiicilis and ^eiuitendinoeue 
muscles, u bursa intervening between them ; it may also send a slip 
beneath the other tendons. It is a flexor of the leg upon tlie thigh, 
and a flexor, rotator outwards, imd slight abiluctor of the thigh u 
the pelvis, thus helping to i)!nce the leg in the position assumed 
the tailor ; whence the name (tailor-muscle). It is supplied by tlie 
middle cutiineous branch of the anterior crural nerve, and j)ierc 
by the middle and internal cutaneous nerves and by the cutoneoi 
Jiattdlie of the long saphenous. 

The QuadiicepB Sztensor is the fleshy mass on the front of 
thigh, consisting of the rectus femorissnjjerficially, with the crure' 
beneath it, and the vastus extemus and intenius on either side. 

The Rectus Femoris (Fig. (jT), 6) has no attachment to 
femur, but stretches over it from the pelvis to the patella. 
aritet by two tendons, one from the anterior inferior spine ofthe 
ilium, the other from a rough impression above the acetabuhigi. 
The outer or rellected tendon may be easily exjiosed by separating 
the tensor viiginns femoris and rectus, and clearing away the fat 
connective tissue from the deep interspace with the handle of t 
scalpel. The two heads unite to form a bi-peunifonn muscle, wliii 
is tendiuoiis on it« uppei surface above and on its under surface 
the lower part, and jnusives to be ultiichcd to llie itpj«er Jnndir an 
anterior surface of the jnUella in conjunction with the otlier r\leii-or< 
muscles, the strong libres which pass in front of the patella fumii 
the sniierlicial ]iortioii of the liganientiim patella; and reaching thj 
tubercle of the tibia, the true insertion of the quadriceps. The 
cnireus joins the buck of the tendon above the ^latella, and the 
vasti are attached (o its borders 



THE VASTUS EXTER.VUS. 



135 



It will lac naticnl Uiat Uii- straight ImmuI la in the axial line of the 
Ituclc liming rxtuiiMiiii uf tlu' thi|;h, the 
pHectcd bea<l liurinj; riglii aiigU* llvxion. Vig. W. 

Burgery. — Tlicnicwl iliivct uml rli);i1)Ip 
IcisiMii Xo muh tilt- hi]i joint vxt>-ii<U 
long ihp iiiltri>piue Ix-twifu llie tetiiior 

iiuie uikI 'wrturiiiH, uiid mure (ici.-|ily 
etwwii tin- rt'ciiu HUii itiucu*. 

Beni'Atll tlie ivrtiiii will Iw 9(»fii tilt' 

•nal rircumftej lintmJi uf tin- JirofuiKbl 

*^ (f'g- 06. ' ' )• 'n''" ati\MM fruui the 

iKt Ktile of the viwiM>l tiear itii origin, 

ul runs tnin»vri«ety U'twc-en the 

niches of the anti-rior criirul nerve, 

the va»tn« eit<-niu« ajul Imnrath 

aancirins hiiJ rectus fi-uiiiri*, to thi* 

: iiiU- iif the lliij^h, when* it ilividf-i 

Ceiidiii^', tniiuivente, ami denoeudin^ 

f branches. The iwriiilinij lirunches 

eiieiilh tlie lenfur fusciie to iiuosto- 

wilh the gluteul and the dceji eir- 

BniHrx ilinr nrteric* ; the traiuntrtr. 

Diippl; Uic vastus extvniiis, and, 

^miu|j round the linil>, nuMtonioHi- 

ith th<! ])«rforHtitih' bmnchtw of the 

whilkt the ddtcevdiwj bnuieh 

into tlie vantuii exteniita Midi 

ncrvr to Uml muscle and cnd« at 

kn«* joint, where it aiiMtomoges 

th the superiiir extenial orticuhir 

»nch of the ]H>iiliteiil. 

The Vaatua Kxternus (Kij;. flS, 7) 

tl»« lnl-x<\»t cif the thiee inUHel4:« in front of the feiuur. It 
fnim the iiulerior border of the yreiit trochanter aa fur u» 
boae uf llui auperiur tubercle ol the neck, front the hiwcr bord«r 




FIff M.— MukIp* of the intcrLur fcmonl region (from ViUon). 



rn>«: of tbe ilium. 

lU aotcrior «u|H-ri<<r ipinoua pro- 

IJlntftm mfHiuft 



Trl. 



feiiiuri« ; iti inwr- 
I'lUkLitt IttlH u laowli 



SnrUniiu. 
tkniw lemuri». 



7. VujiluN (ixt*<niu*, 

8. VMiiia intomua. 
tl. l-itU'lLi. 

II). Ili.ii^iu inUtrnua, 

11 rMiAfl iiiaicnut. 

I'i. IVrtiitviu 

I.'). Aililuitor loriiinii. 

14. I'art of the iiUductot iniL|ni>. 

J a. (Jmcilia. 



1S8 



INNER SIDE OF THE THIGH. 



Surgery.— Dentation of the femoral artery in !Iunter*« 

18 not frequently perfornieil in the urescnt iluy, but tlie 
is i-eadily readied by an ineisiou to tiie inner siile of the va 
intemuB in the middle third of the thi^^h, at the outer edf(e of the* 
Kartoriu*. The sart^inus is turned inwards, and the sub-saitorial 
fiiKciii is brought iutu view ; tins beinj^ ilivided the artery will 
exposed. It is most convenient to pi>«s the aneuiisni-neetUe fr 
without inwaixls, the vein lyinj; to the outer side, nnd ^reot 
must l>e exercised to avoid piercing the closely adherent veins. 

The Anterior Crural ITerve (Fig 69, 5) supjilies branches 
all the muscles of the fnjnt of the tliigh fxcijit the tensor tt 
femoris, and also gives a branch to the pcctineuw on the inner si 
of the limb. The Imuich to the sortorius has been nlrea^ly seen 
arise from the middle cutaneous nerve, and the remaining branc 
can now be traced from the deep division. The nerve to the vasi 
intemus (19) and that to the vastus extemus both supply sun 
twigs to the knee joint. The nerve to the pectiiieus, whicli is o: 
double, (10) crosses transversely beneath the femonil veijsels to the 
surface of tlie |>ectineus niuflcle. From several of the uji] 
muscidnr bninches twi^js are given to the hip joint. 

The Internal Saphenous Nerve (Fig. C9, 22) is the long' 
branch of the deei" ili\inion of the anterior crural nerve. It lies cl 
to tlie outer side of the femoral artery, and enters Hunter's carnal with 
it ; then crossing the artery near the lower end of the canal it pierc« 
the sheath, appearing beneath the sartorius at the inner side of tlie 
knee. In the thigh it gives a cummuniealing branch to a subsartoi 
plexus formed by the internal cutatieous and obturator nerves, 
at the knee its inlerual patellar branch pierces the sartorius and 
in the patellar plexus. The nerve becomes cutaneous between 
sartorius and gracilis, and runs down the inner side of the leg 
foot. 

Inner Side of the Thigh. 



the 

>pe^ 

4 

•ith^ 

rc« 
■ the 



[The suiierfieial imiacle of the inner siile of the thigh (adiliicti 
longus) is already parliidly seen; to expo»e the rest of the regie 
an incision is to be iiiude along the mini of tlie piibes and ischiui. 
and llie skin is to be relletted, when the gracilis will be brough 
into view. The femonil vessels must either lie cut ami turned do« 
or pulled forcibly outwards.] 

A few cutaneous branches of ner\'e to the skin of the inner sifl 
of the thigh will be found appearing below the adductor long 
They are derived fiimi the obturator. 

The Adduotor IjongUB (Fig 65, 13) urUes by a round tend 
from Uie front of the os pubis immediately below the crest, 1 



THE PECTINEU8. 



189 



I to be inttrted into tlie inner l>i)rder of the liiiea a9[)era, in 
tli« middle third of the bone and into the int-enml intenuuHciilar 
•eplum, blending with the insertions of tlie adductors brevia and 
migniw. It is tnpftliM by the BuperKtial division of the obturator 
nervt In the middle thinl of the thi^h it separates the superficial 
[mm tlie deep feiuonil vessels, the luttttr disiippeAriny from Scarpa's 
diuigle l)etween the adjacent bonlers of this musi\le and the pcctineus. 
The Oracilis (Fig. 66, 20) is the uioal internal of the muscles 
«f the ihigh, anil arixi from the rami of the os pubis and ischium 
by II liroad thin teudoii about tliree inches wide. It is iuMrtid into 
lb* inner surface of the tibia under cover of the sartorius and abovo 
tbe wmi-tendinosus, a bursa intervening between it and these 
■mkIci. It in ttipplied by the superficial division of the obturator 
.aenrt. 

[Tlie adductor lonjpis is to be divided near its origin and turned 

f •0*11, III oHer to expose the adductor brevis and the in.sertionsof 

mwctiurus, psoa-s, and iliacus. Thebnuicli of the utiturator nerve 

t muscle is to be jireserved, and the profunda vessels are to be 

1 M far as exposed.] 

The PectaneuB (Fig. 66, 4) has been already seen in relation 
Wh ibe feinonil artery and forming part of the floor of Scarpa's 
™ngle. It <irisc4 from the inner ](art of the ilio-pectineal line and 
f"™ tlie triangular surface innnediately in front of it, between the 
pubic jpine and the ilio-pubic eminence ; and winds to the back of 
lie femur to be inierttd into the upper part of the pectineal line 
"■ling from behind the trochiuiter minor to the linen a«iH;ra, a 
•tsw interrening. It is iupylicd by the anterior crural nerve and 
■mrtunes also by the obturator or accessory obturator. In front of 
It tit the femoral and profunda vessels and jiart of the anterior crural 

f. the internal circuniHex veRsela wind over its ni)per border, the 

XoBdA vessels disapjiear from Scarpa's triangle at its lower border, 
ito deep surface is in relation with tlio obturator externus, 

'•ddnctor brevis, the superficial division of the obturator nerve, 
••i lie inner jiart of the capsule of the hip joint. 

The pectineus should be divided and turned aside, in onler to 
igllie deei>er jmrts into view, rix., the olilurutor extenuis and the 
™<inil<.>r nen-e, with tin- accessory obturator nerve, if piescnt ; a 
^tofihe hip-joint, ami more of the internal circumflex artery than 
™jtt lieeu i>evn.J 

loaertion of the Psoas and Iliacus. — -The two muacles arc 
'"DJoined its they enter the thigh ; the psoiis is inserted liy teudott 




140 



INNER SIDE OF THE TUIOH. 



into the small trochanter, tLe iliaciis by Heshy fibre* into the tulidon 
of the pBoas, nnd into a triunguhir murk on the fenmr Ijflow I 
small trocliant^r luid in front of tlie jn'ctineus iiixcrtirin, 

Tlie Adductor Brevis (Fig, 6«, 1 8) hns thi- »iii>erlicial iliv 

of the olitunitor nerve lying up 



FiR. 66. 



it, iind the deep di\i»ion of 
sjinie ner\'e botween it 
the adductor mngnuit. It itriw 
from the front of the pubic 
rutiius, below the adductor longuj 
and betwoi n the gmcilia 
i>l>turator extemus, and )8 
nerteil into the whole of the 1 
leadiiijj from the leaser HO- 
chanter to the linea .i , ^ 
beliiiid tlie pectineun Mxd . 
part of the adductor longiki iuul 



»f- 



Fig. 68. — ProAindH artfry mjil ili 
bmnchot (Bonamy and Omu). 

1. Iliacui. 

■i. I'ww*. 

3. Exteniiil iliac artery. 
4 Iiitvmnl iliac arterj'. 
o. Deep cirouiiidex ibac. 

6. Deep epigiiatric, 

7. TciiHor vagiuiB femoris. 

8. Common femonil artery. 

9. Supt'rti<'iiil femoral artrry. 

10. Symphv»i» pubis. 

11. Lxtcnial circuiiiHe.x artery. 

12. .Vdilui'tor loii^iu (origin). 
111. Vastus cxternun. 
14. Peclincus. 
1$, AtlUuctor loiigus (iiucition). 

16. IVofuiKlii (tuu largp iu the draw* 

ins). 

17. Crurcus. 

18. Adductor brevis. 
10. Femoral iu HuDter'n canal. 

20. Gnioilii. 
'21, Vastus inlcmua. 

22. T'urt of adductor iobkuu*. 

23, I'utella. 

21. I 'art of adductor mugnus. 
2o. Ligamrutuin putellip, 
26. .Scmi-mcinbruiiosus. 
'la. Anustomotica niajpia. 
30. Supiritir iiitcmitl arlirul 
32, Interior intiuiiul artinular. 



THE PROFUNDA AUTEllY. 



141 



rfront of the adductor inagnus. It is tupjditd either hy tlu- di-ep 
or by the sii]i«rficial branch of iho obfnrator nc:ve. 

Tlif aiium of the luidnctor? longus and brevis i» to some extent 

im])lif<l l)y tlieir name, but they are also llexoro and external rotii- 

loBof the thigh. The adduction if combined with flexion can l>e 

tutieil beyond the middle line, so as to cross the thi^di over the 

iipikisile limb. The pectiueua is also an adductor, external rotator, 

oitl llixor of the thiyh, and the graciliH is an adductor of the thigh, 

»A in addition a Hexor and an internal rotator of the knee. All 

tk« rausclus of the inner ?ide of the thigh nre sui>plied by the 

tor nerve, except the pcctineus, which receives its nerve from 

Mterior crural, with sometimes an additional twig from the 

«tor or accessory obturator. 

TW FroAinda Artery (Fig. 66, i6) has l)een seen to ariw; 

from the feinnnil artery in Scarpa's triangle, from one to two inches 

Wow PoujMirt'f ligament ; lying at fii'xt to the outer side of the 

'••Ulllll artery and against the iliacn.'<, and then winding inwards on 

*> ll* peclineus behind the lenioral ve-iiscls and it.s own veins. It 

•ttt puses below the bonier cpf the pectineus behiml the adductor 

""HPiB, which sepamtes it from the ."luperticial fernond ve^jsels. and 

Wtothe lulductor brevis and niagnus, ending by piercing the latter. 

Hw jnofiuiclii vein is superficial to 'tu artery iu the whole of its 

_niDK. 

Tlie Branches of the ProfXinda arc the external and internal 
nllex, three jierforaling arteries, and a terminal branch, 
I branches to the muscles on the inside of the thigh. 
. The Extfnial Cirntmflex urteni (i i) arict'!* fruni the outer .lide 
lilt profunda near its origin, and ha.f lieen already ."een in the 
; of the thigh (p. 13.0). When this vessel, as is not unfrc- 
^. ,' tlie ca.sc, springs from the cummon femoral, the upper part 
■•i* profunda is no longer external to the superficial femoral, but 
1* behind or internal to it. 
2. Tlie Inlfrnnl Circnmfif.r urteri/ (Figs. 67, GS) arises from the inner 
*0[the profunda near its origin, and passing backwaixls between the 
lind the pectineus, reaches the obturator extenius muscle above 
>lddoctor brevis, where it divides into two terminal branches. 
1 igpplies twigs to the muscles on the inner side of the thigh, 
lUiMtomotic branch to the obturator arter)', and an articular 
ith to the hil'-joint. Of the terminal branches, one foilnvva the 
HJon of the obturator extenius to the digital fo*»a of the great 
■nter, supplying the external rotator muscles and ariiustoniosing 
•ill th'; gluteal, sciatic and tii-st perforating arteries ; the other 
I to the Ijack of the thigh between the quudmtiis feiuonii kuCl 



142 



INNER 8IDE OF THE THIGH. 



« 



Femoral iirterj' 



Psoiu and Iliariu 

Internal Circumflex A. . 



Peotinetu 

rroAindn ort«ry 



Superior PerfomtingA. 

AddiKtor brevis 

Middle Perforating A. 
Adductor Longug .... 
Inferior Perforating A. 



Adductor Mapiue .... — I 



the adductor ina^rnus, and supplies the upper part of the ham- 
atrings, anaatouiosiiig with the sciatic and first perforating orteriM, 

and ocajsionally with th« 
*"'6- 67. extemiil tirciunflex. Thii «o- 

called "crucial anmtomont' 
iMJtwcen these four Teasel* ii 
seldom denion*trabIe. 

3. The Perforating artrrUj 
(Figs. 67, 68), tyjjically, 
three in nuuiWr, pierce th 
adductor ninsclea to SQ)iph 
the ham-strings and tlie vi 
The gupnior and miM 
arteries perforate the 
ductors brevis and inngniui 
the inferior ariries below tli 
level of tlie addnutor brevi 
anil therefore perforates onlj 
tlie adductor iiiogniis. 
nutrient arterj' to the femu 
gent-nUly comes from thd 
middle perforating aitery, an 
when entering the foraiud 
in the linea a8]^iera ha 
a direction from the Itne 
joint 

4. The Ttrminal brnvekl 
(Fig. C7, 68) ends iu 
fibres of the adductor magniu 
or pierces it to join with i 

inferior perforating and superior intenial articular. The three perfo 
rating and terminal branches form a chain of anastumoscs in and 
behind the adductor magnus. 

Tlie Profunda Vein receives branches corresjionding to those i 
the arteiy and ends in the femoral vein. Il is superficial to 
profunda artery throughout. 

[The adductor brevis ia to be ilivided in order to expose the de 
portion of the obturator nerve, the mlthictor magnus, and the obtur 
tor externus, which are to be cleaned.] 

The Obturator STerve (Fig. 69, 8) is derived from the second,' 

Fig. 67.— Dinpram of the profunda artery of the thigh (drawn by J, T, 
Gray). 




THE OBTUBATOn NER>'E. 



143 



' anJ fotirtli liiiiJuir iiervti*. It lenvtm llie pelvU nt the up{>or 
{•art of thr ol)turutoi' foninifii 



with thu o|)tiirHt<ir urttry, uail 

• liviilr* into KUJK'rtli'inl 1111(1 Jeep 

im iM'forc pierciti^ the oli- 

n- i-xivrmm. The lujit-r- 

jiruti (livisiou lies u|Hm the ml- 

ilii. ii.r brevis onil i<upplii>« the 

''IT longiis, the (ulduclor 

i J . . i^ and the gracilia, ({iviiiK off 

fiUuiic-nl« tiiu/ tt) tlie «ulj6iirtiirial 



Fir W. 



. «8.— DJ»p«m of uterira »f tJiigh. 

• .•rj-. 

rt'frf. 

^ iliiK'anutoinotiDr 
iixrofliittirniihliac. 



I). 

lu- 
ll. 



ilivldiii); into mi- 
1. .:^r tniiik». 

^n). (ShuuM 



Ktlrriiu! ihuL, 

{>mr<ii[linf hnnrb of cxtrrniU ci'- 

'f.-v. 

11. ropiit«i. 

>u^ : iiul mii'HiIiir. antui- 

' 'U rxtcnml rirciiin- 



Ini 

ll.. 



>il ■rlirulnr. 

: liraiu'li of iiilvmal 



r.'> ' .1 rccunrnt (from 

aulrrint ubml). 
Safttriieinl frninral (muwuUr 






All"- 

-ffl. All' 
24. P. I 



nl. 
'« of <lc<i|i 
-ii, iuiiuiii^ NtiuNtiitniitio 
and •iipplyiii^ I'Oftcriui 



'-• off miprtior mu*- 



St' ; .ill uriiculiir. 

Inl ' ll Hrtimliir (mral 

siioiu'i unuiig bcluw tliii 

<.mltt«l). 
r(wt>riar tibial. 




144 



JNNER SIDE OF THE THIGH. 




plexus arul iin urticulnr branch to tbe hip-joint The drri> divisioa 
Bupiilies the oUtumtor extemua iinil, alter passing liehind the sd- 
diictiir brevis, gives a brunch to tlie aitiluctor niagnu?, and !iend» 
an nrtieuhtr tllaiiicut through tlii.s inilBcIc to the back of the \ 
The adductor brcvia is soinftimes supplieil by this divi.sion. 

An Acetjiuyry OMurator 



Tig. 69. 



iiend* 

' nam] 




18 occasionally found paKiing 
from till! thirl witl fourth nerves 
of the lutiibar plexus, over the 
pubic bone to supply tlie jmsc- 
tineua, or to replace more or le» 
Ihc superficial division of the 
obturator nerve, 

Tlie Adductor Mag;nus 
(Fig. ()6, 22) uriitri from the 
external part of the ramus of the 
lis ]iubis, from (Ik- nunus of the 
ujchium, and from the lower 



Fife. 69.— NerTM of the thigh (fnai 
UirKhft'lil and Lfvcillc). 

t. GanKliated rnrd of synipathetUa J 

2. Tliirii Itiiiibiir nerve. 

3. Unmrhea to the iltuous interna 

4. Fourtli lumlmr nerve. 

5. Anterior oniral nerve. 
G. bunibo-sncrnl ncne. 
7. Hninch to peouR. 
K. (»bturiiU)r nerve, 
y. K.vtemnl cubineoiu nrrre (cut)i 

10. Nerve to pci<'tineu». 

11. Kuperfieial iliviaion of sob 
crunil TitTve (cut). 

V2. Supei'Ki'iiil division of obtu 

nerve. 
I.'S, 13. SiirtoiiuB. 
14, 14. .Vdductor longtM. 
.). Branch to reitu». 
Iti. UFe|i divL'ion of obturator no 

1 7. Ilniiirlic< to Tiutiu extemua tnJ 
(Tureus. 

18. Adduilur brevia, 
U). llraiieh to vaaluii inlenius. 
20. .\dduitor itiu)piu<i. 
'21. Vimtiij externu.i. 
2'2, 22. Intemiil ui|dii'noua nerrs. 

23. Iti'olin feni'iri*. 

24. Pul«llur bmnch of aapha 
niTvc. 

25. VaatuB intcrau). 

26. Orarilis. 




THE ADDCCTOE MAGNUS. 



145 



t of tile uchial tuberosit)*. Ita anterior fibres jmss outwards, with 
Wtfeat degrees of obliquity, to be hinrtid into the back of the 
Biut immediately below the quadratus feiiioria down to the linea 

Fig. 70. 




, and may be separated from the rcRt to form an "adductor 

mil" \ the middle libres jiaos into the whole length of the linea 

,ind a small portion of the line leading from it to the internal 

Jvle; while the posterior ischial tibrea (24) run vertically down- 

> to end in a round tendon, which is injiertefl into the tubercle 

!the inner condyle of the fi-raur, and, by means of an expan- 

linto the lower jiart of the line leading to it. This tendon forms 

' «reh for the passage of the femoral vessels into tlie popliteal 

! nod gives origin to the lower fibres of the vastus internus. The 



ft- 70.— Section of th« right thigh 
G. E. 

I. PraAmda veaRU. 

* Addnctor longtu. 

*■ Pononl reasrU. 

i Saper6cial obtuntor nerve. 

t Strtoriu*. 

('Gndlii. 

'' Xxtrnial cutoneoui ncrre. 

i Fwliiieiu. 

'. BkIus feinorif. 
JO. .Adductor brevi*. 
11. Antmor mini nerTt. 
B. 



ut the apex of Scarpa's triangle (drawu by 
L. I'earte), 

12. Depp obturator nerve. 

13. Extcrual circumflex vessels. 

14. Adductor mnj^uti. 

l.i. T^rn^or vn^rinie fenioris. 

16. Semi-niprabniiiriBus. 

17. Vnstus iuteniufl aud erureuji. 

18. SL'mi-tendinodUfl. 

19. Vastus exteruus. 

20. Small sciatic ncrvo. 

21. Bicepa fcmoris, 

22. Grc.it sciatie nerve. 

L 



146 



THE BUTTOCK. 




muucle is mipjAifd by tlio obturator iiervo, and also by the great Bciittj 
It ia a powerful adductor and external rotator of the thigh, and i 
vertical posterior filires also aid the hamstrings to extend the hip. 

Above the u]iper ImnVer of the adductor uiagnus a j)ortion of the 
Obturator Externus can lie seen. It «n'w»- from the anterior ( 
inferior niJirf;ins of the obturator foramen, and from the aut< 
two-tliirils (if the outer surface of the oliturotor nienibrane. 
fibres aie directed outwards and liackwards, and end in a tend 
which pa=<!iea below the acetabulum and behind the neck of 
femur (a bursa intervening), to be iiieaied into the digital fo8.*a of I 
femur, as will be seen in the dissection of the buttock (page 151) 

Tiie oljtunitor cxtemus is an external rotator and adductor of 
thigh, and i.s tupjtiied by the obturator nerve. 

The obturator ai-tery is l>est »eeu after the removal of the thij 
from the pelvis, in the dissection of which its description 
included. 



The Buttock. 

[The b(Kly being tuiTieil on itw face, the buttocks are to be : 
by blocks beneath the judvis until the thigh van \w well Hexed ydi 
the knee on the table, or, if preferred, the legs may lie allowed f 
hang over the end of the table.] 

The dissector should recognize the crest of the ilium, ■which 
bound his dissection superiorly, also the siicnim and coccyx, and ' 
tulwrosity of the ischium. The hitter can lie felt through the glut 
maxiniu.'. in the extended position of the limb, or imniediaU 
beneath the integument when the hi]) joint is Hexed. The relatio 
of the tixjchaiiter to the several port* of the pelvis in the diffe] 
positions of the limb art of great practical importance in the diagna 
of fractures and dislocations, and should be airefully examine 
The ''fold of the buttock" varies according to the amount of 
and the muscular develojunent of the subject. It should 1)enotia 
that it doi's not coincide in direction with the oblique lower bor 
of tlic gluteus maximus but when the limb is extended runs i 
htiri/.ontally outwaixls, crossing the muscle near its middle (Fig. SS 
The prominences of the inner and outer hamstrings and the hoUo 
of the ham will be seen during Ik-xion, and it should be noted hc( 
readily the space can be explored in this position owing to the i 
laxulion of the fascia. 

[An incision is to be made along the crest of the ilium, and dot 
the middle of the sacrum to the tip of the coccyx, when, if f' 
periuieuni and thigli have been dissected, it will only be ne 



THE OliUTEUS MAXlMrS. 



147 



nalcB uliollior cut m.T<j»» Uie iip|>*r pui-l of iLf bwk of the tluVli. 
tiwiiij' tiic folij <if th" liuttiH'k <ilili()iit"ly ili^wuwunU and outwurdft, 
*luw the UirRe tini) of skin t^i be iiiHectiti uiitwiuxla,] 

the amount of fnt Ix'iiitnth thi' xkiii rif th» biittiKk vanci) cun- 
My, un<l if then- in n lur^L* ijuautity it iii iiutudviaulilc tu ajjcnd 
ill IcHikinjj for (.ul^iin'omi uktvim. 

the Outaneoiia Nerves are duiicvniliti}; anil ascending. 

7i« df»-r>uhmj liniuclic» will be found piujin){ oviT thi- middle of 

fcrutt of tlie ilium, iiiid urt- thv iltiU'. bram^hvs of the liut dorwl 
ftmt luiuliar liliu-liypogiistric) iien'<«, the fornuT iH'ing in 
of th(! hitter. Thi't'c sitv a few bramheit iilxo drrivtil from th« 

trior diviMoDs of tbt,- upjicr microl uurvct, \t)iiuh ]>um from thu 
r)f iiw xacrum. 

111! (utriuliHij braiicheii are derived from the liitscr aciatii: ncrvo 

tturu round the lower bonier of the );lutMw mnximtia, to «upply 

' utegumenl over tlic lower juirt of the buttock, 

be iMirtioD of deep fksoiii coverifiR the Kliit«UH infdiim and neeu 

ont of the|,;lutvu8niiixiniiiii U to be cleaned, mid thru the |{liiteuit 

mil ilwlf, the tilires Ix'in^; jmt nn the sitreteh liy lle^iii); und 

rtin;; ihe thi^di, and the diriM-elor be>;innin}; at tlie upjier iHjnler 

be luuw'lv uii Ihe rij;lil, und it« lower l)ot\ler on the left limb.] 

be Olateua Maximus (Fig, 71, 2) rtrurn from the ruui;b 
glo iK'lween the Ilo^^erlor ihihl of the crwt of the ilium und 
tl>eriur curv'ni line un the <lonium ilii ; from the lumbur fajtcia, 
iLc lower jjort of iho wicruui, an>l the Bide of the timt three 
of the c<K'cyx; and by deejj libre.f from the ponlerior nurfnco of 
ILe gmit Micro- sciatic ligniiielil, which will be «een when the muscle i* 
divided. Tlie tibrcs run downward* und oulwanls, und the upjMsr 
^laU of the miiHcIu i» iiurrttii iuUi the fit.4cia lata (ilio-tibiul bond), 
[lower half Ving alou attAched Niiperficially to the fiucia, but 
ly to the routjh gluteal ridge loading from the bock of the 

liter major to the linea aHpeni ol the femur, 
be gluteus maximiu) iit one of the mont important raiiHcles of 
slower extremity. Acting from the pelvia it in a jKiwerful exten»or 
cxtenml lY.lz-.lor of tin: thigh, and a tensor of the fiisciu lata, 
it* I - aid in lulduction. Acting from the femur it 

ndidii Ihc trunk. It i* tupplifil by the inferior gluteal 

e, a bmnch of the wicral plexus or of the small sciatic nerve 

- itt t4i 1k< divided near its origin and turned down, 

hmeiit to the »aci<u-ftciatic ligament alxivr ainl the 

iH will l>e better Keen. Some branches of the gluMd. 

L % 





148 



THE BUTTOCK. 



artery at the upper, nnd of the sciatic at the lower part of tht 
muscle must iiece*sirily be divided, Init the nerves going to it;* unda 
surface from the small 'sciatic should he preserved if p^xwible.] -* 



Fiff. 71. 



Three buna will be found in connection with the gluteiw moii- 
mu8 : one between the upper juut of its 
tendon and the great trochanter ; a wrcoml 
between the tendon and the vnntus a 
temuB ; and a third over the tuberosity of 
the ischium. The hitter is «ubcutuni'UDi 
\\ hen the thijjh is flexed, but is coveiwl by 
the muscle diirinjj extension. 

The Farts beneath the Olutems 
ICaximus (tigs. 72, 73) can now he .•kvu, 
covered by loose cellnlur tissue, whi'h i* 
to bf removed. They are from alwni 
downward.s: — 1, gluteus niedius; 2,sii]«sr 
(icial l)riinchcs of the gluteal veastl* ; 3, 
]iyriformis muscle ; 4, sciatic vessels atid 
nenx's (great and small) and inferior 
gluteal nervb ; 6, piulic vessel* and nerw, 
and nen'c to obturator intomus ; 6, 
tendon of the obturator interniis with 
the gemelli muscles above and below it; 
7, the, tendon of the obturator exterotu 
ut^nally concealed by the inferiur gt^mellot 
and iiiifldratus ; 8, ({uadratus feiuoris and 
U]iper border of adductor uiagnUM ; 0, giral 
fiacro-sciatic ligament ; 10, tulier iscliii 
and iiiu^ck'ii att^tched to it ; 11, termiml 
branches of internal circumflex vesseli, 
ai)pcaring above ajid below the ijuodrotni 
fenioris ; 1 -2, the upper end of the femur 
with the vastus externus. 

[Tliese stractures are to be cleaned u 
far as possible at once, and will be ex- 




FJK. 71.— Muscle* of tlic pottcnor femond and ghiteal region (ftt>ni WilsoD.)!:! 



1. Gluteus incdius. 

2. (itut«uB miixinius. 

3. Vaalua vxlernus covered by fiufi* 

luLi. 

4. Long bL-nd of bicopa. 
6. Short beuil of biceps. 

r'6. Bemi-tcudiuoaut. 



7. Scmi-niembrunoaus. 

8. GmciliD, 

9. Furt of the inner border of < 

iidductor mugauft, 

10. Kdjic of nirtoiiui, 

11. l'o|iUteal spnco. 
)-. LinatrocDCQiiut. 



THK PVKIFORMIS. 



U9 



Will 

m 

W ton: 



ainuie<.l in Kucosednn. In onlcr to olrnn tliR mnsriua, the tliish 
IBVt»l \tv wi'Jl ixiUiU'd iiiu •i-.l- nfi.l for the xlutfua iiitMiiai, it muHt T)« 
ciii«<cii liedtvith till' ■ ; 111". Cure wlioulil W tiikvii t" jito- 

■erve an «iiii»tunii>MiK lietweun tin- tulur JM-liil ainl git-at 

trochanter. J 

Tlic Oluteua Medius (Ki).'. 71, i) nrucj fruni nn una u|H>n the i 
dorniim ilii IkhiiiiIuiI l>y the superior luid middle eiirvc<l liiie« itnd the 
anterior fmn-fiflij» of tin- extfrnnl lip of the iliiu: crvHt ; and fnitn 
the fuMoiii Itttti c^iveriiiK it uIkiw the glutciut niuxiuitix. 'Die librea 
convf rg« t» b« fnnerUti into tiie diiiguiiul line uf the (jreut truchunt4sr, 
ttxtendiug from il» jKMlerioriiupenur iinglo obliquely Jownwudji and 
(bnmnli. 

The uutcrior iKmirr of the k''"!"'" nicditw is fref{uently nnit«d 
with thiit of llir iitiiiiniiiH and with tliv ilio-th».'hanteric bniid, whii'h 
J'enetilh it, 'Yhit iiixertiou of tlie gluten* niediun i» beat seen 

en the muscle htu) been divided. Two Imrtm will be foiuid in 
connexion with it» tendon, one Mei>urHtiii){ it from the ourfufe of th* 
greot triiehauter iibove the diiigoiuil line, the other from the titndon i 
at the jiyrifiu-mix. 

[Tlio x'"'*"" niediuN is to lie divideil rliwe to it« ori((iu without j 
injuring' the glutnix miiiimuv, the xepanition from which i« marked' 
|i} :\ ; niid the anterior li<irdci->« of the miwcleH ImvinK l>een 

i» j ith the tical|«'l, the cliitenx medius iit to Iw tiirne<rdowit 

witrioiii iiijiirini,' the veweli! luiil nerve* licnunth.] 

The OlateuB Minimoa fFig. 72, 8) aruei from the urea 
liuuaited by the middle uwl inferior curved linen, the upper ]uirt of 
the Anterior iimr^in of tlie great sciutic notch, and the anterior 
border of the ilium as fur a» the anterior inferior npine. It \» in- 
terUtd into the anterior borrler of the great trochanter. A hurta ih 
usiully found U-twron itx tendon ami the troclmiitor. 

The two Rmiiller glutei uctiiig froin their insertion iiicliiio 
the trunk laterally towunU the snmo niile, and aiil aImi in llexton, 
estrnAiuu, and rotation. If the jielvis be lixed, they act us ulH|uctor» 
«f the tliigh and u.'<»i»t in the movements of Itexiun, extension, and 
rotation of the limb, the anterior portions of iHith muscKii rotating 
inwanU and tlexing, the po^teririr portions rotating outwards and 
extending. They Ar« l>oth tujipUal liy the sujierior gluteal nerve. 

The Pyrifonnia (Fig. 72, 9) aritr* inmi the front of the lateral 
moaa of the sacrum Wtweeu the 1st, 2nd, 3rtl, anil 4th Mcral 
foroiuiua OS well ns from the grooves external to the fomminn, also 
from the ujipcr part of the great sciatic notch, and often from the 
ifTtat Micro-sciatic ligament ; pouing out of the great fuuto-aciftlia 



uai^ 



150 



THE BUTTOCK. 



foramen it enrls in a round tendon, whieli cro8.«pa the tendons of the 
obturntor intemns and gemelli and is inm-rtw/ into a diatinct deprw- 
sion at the post<>rior part of tlie upper luarxiu of tlie great trocbmiter. 
The muwle is owasioiiolly divided into two parts by the pafls«(;« nf 
a portion of the p-eat sciatic nerve through its fibres. It is ao 

fxternal rotator and abductor of 
F'K- 72. the thigh in tlie extended pcw- 

tioii, and an alHluctor when the 
limb is flexed. It is mtyjilui 
by n special branch of the sacnl 
nerves within the pelvis. 

The Obturator Intemu* 
and Oemelli (Fig. 73, li).— 
()nly the tendon of tlie obtu- 
rator intemns is now seen, ih* 
muscle aritring from the inner 
>\irfuce of the true pelvis anjuni) 
the anterior two-thirds of ibf 
.ibturator foramen, and fnim the 
rorrespindingjB^rtiouof theiuiiet 
s\irf«ce of tlie iilitiirator luem- 
liraue. Tlie tendon winds oat 
of the lesser sacro-sciatic foramen, 
and, being joined by the gemelli, 
jiBiwes forwards and outwiinli 
beneath the tendon of the jiyri- 
formis (with which it is inoiv or 
less united) to be inrrrleil in front of it into a dejiression at the 
anterior part of the ujiper margin of the great trochanter. The 
gemelli (twin muscles) do, 12) are placed iiViove and below the 
tendon of the obturator inteniiis and are inserttd into its miirgina unJ 
deep surface, but one or both may be absent ; the superior ariia 

Fig. 72. — Deep musclei of the gluteiil region (from Wilson). 




1. Ilium. 

2. NiiiTum. 

3. I'osterior urro-iliac lipiment. 

4. Tulierosily nf the iRchium. 
6. Great siicro-xoiatio ligiiincnt. 

6. Lesser »!icm-»ciRli(: lipinicut. 

7. TrcK-hnntcr mHJor. 
K. Olutriit minimus. 
U. I'jriformi«. 

1(1. (icmellui aupcrior. 

The tendon of the obturator extcmus »ppeaii< between the gemellus inferior 
uid the qusdratus feinoriK. 



11. (Jbturator intemuft, putting outot 

the leoer aaero-aoialic fort- 
men. 

12. fJeniellu" inferior. 
\'i. QuiulnituH f<!mori«. 
11. Addui'tus miifrnu.^. 
15. Vastus extemus. 
Ifi. Bii-cpn. 

17. Gracilis. 

18. Semi-tendinoius. 




THE GLUTEAL ARTERY. 



151 



from the extcm/il gnrfiioc of the s|iinc <if tho imliiiini lUiil luljitocufe 
portion of the l«j>«tT sciatic iifitch ; thi< inferior «n*-j< from ihe upijerl 
anil lKu;k part of Ui« tuber LtchU, and ia llie luryet uud more con- 
■tosit luuxle. 

If tb« t«iidoii of the obliimtor iiitemiu be divuled near it« tngitr- 
lioti without di^tnrbidg tho gmncUi, luul drawn iii) from the nuirgin 
nf the Dciutic fonuiien, a Inr^e bur«k will be fniiml, whieh, when 
opened, will be seen to lubricntf the umb-r Riirfnce of tliv tendon and 
the luui^in of the le-*!er sn-w-xiatii- foranion. A iwcond bunw, 
»on)etiriii-8 cjuxmiinictttiii;,' with th"' tir»t, lie* between the tendon 
f<nil thi' i.ai>f.ule of the hip-joint. The i«ehiul >urfuce of the 
■1 ill Mibdivided by two or three deep Krooves, and the margin 
l)One if. encrui'ted with utrtilugi! which pn'nwntii ridgcn corre- 
»p'in(iin<; with thes<'. 

The (ibtunitor intenius and genielli on- alxiuctoni and rotirtom out- 
waiiU of the thi^h when it i« extended, but abdueton only when it 
t« alrewiy flexed. The obturator in miiipUfd by n iipectal brunch from 
the upper ijart of the nacrul plexus, whuh also {{ives a branch to the 
I ,r gemellus ; the inferior (;eiuellus i« niyplied. by the ncrvn to 
idnttus from the oacrul plexus, 
the Tendon of the Obturator Sxternus (Kig. 73, to) will 
bo found lyin^' deeply Lelwirn the mfiTior ){eiuolhiit and the 
<pta<imtiui muscle. The ori>{in of the niuitrle ha.i been alreuily Keen i 
140), and the temlon, aft^r ptuwinj; throu>,'h the j^tiove belo« 
ai'etubulum, it vtterUti into tlie digital foxKa at the hhiI of tlie 
trocluuiler. It \» in clu<e relation to the iipp<-r temiino) 
tjch of the intenml circumllex artery. The obtunitor cxtnrnui) 
f« rotator outwardx and u feebh- adductor of the thigh, and is 
fptiftl by the deep division of the obturator nerve. 
The Quodratus Femoris (Fig. 73, 24), ho named from tta 
qnoilrilateral nhajie, ariurt from the outer iiide of the tuberoiity of the 
Ilium extenially t<» the hamstring luuwles, and paanes hori/.ontally 
twards to lie iit*crU»l on an eminence on the back of the femur 
»r1ow the middle of the poxterior intertrochanteric line 4nd immn- . 
diatcly above the adductor magnus, with which it iii sometime* ' 
oontinuoua. Tho point of inxertion ha.i been termeil the '' liuea 
quodrati " Utough a distinct line seldom exists at the spot. The 
niuncle is an external mtator and ailduetor of the tliigh, and is 
ruyi'liaihy a special bnuich fhiui the Moral plexus, which uUo gives 
a twig to th« gemellu« inferior. It 1« Mparated from the IcMcr 
trochanter by a bursa. 

The Oluteal Artery (Fig. 73, 5) is a branch of the posterior 
I of tlie iiitenuU iliac artery, and emerge.s from the pt^lvU 



i 



152 



THE BUTTOCK. 



Ihrough the great socro-aciatic foramen above the pyriformUi It 
appears at the lower border of the gluteus mini inus, and brwiksnp i;i'i 
Bujierficiiil and deep divisions. The siijxrrficinl division is distribn ; 
the under unrface of the gluteus uiaxirau8, and its root nmy be lumm 
at the junction of the upper and middle thirds of a line runnini^ 
from the p<isterior suivrior iliac space to the posterior superior angle 
of the gi-eat trochanter (Fig. ."iS). It anastomoses in the gliUrus 
inaxinius with the inferior gluteal branch of the sciatic ait.n. 
and with posterior brunches of the lateral sacral. Unlike thi i i[' 
division it is unaccompanied by a ner%'e. The deep division "iili- 
divides into superior and inferior branches. The sajmrior In-iinrh 4j 
runs along the middle cur\'ed line of the ilium between the gluttiu 
medius and minimus ; both of which it supplies, and ends at tb 
anterior border of the ilium by anastomosing with the sup 
branch of the external circumflex and with the deep circumflex ilii 
artery. The inferior branch (6) crosses the gluteus minimus to I 
great trochanter, to supply the jiarts in its neighbourhood and em 
in the tensor vagince femoris, onastomosing with the external cincna 
flex and sciatic arteries. 

Veit/r coiuiits accompany the branches of the artery and open 
the internal iliac vein. The bninchus of the deep division are 
accompanied by those of the superior gluteal nerve. 

The Sciatic Artery (Fig. 73, 13) is a branch of the anterior 
division of the intermd Uiac artery, and emerges from the {lehis 
through the great socro-sciatic foramen below the pyrifonnis, where 
its position is indicated by a point at the junction of the middle 
and lower thirds of a line running from the iioslerior superior iliac 
spine to the ixchial t^lx^^osity (Fig. !)i). It gives lai'ge tii/cti 
gluteal biwichca to the gluteus maximus, and miinadiir brunches 
the other smaller muscles of the neighbourhood, accompanying thd 
l-espective nerves ; and aniistoiiu:)ses with both the external and : 
ternul circiuuflex arteries of the ]>rol'mida lemoris. Its nun 
branches are, 1, the cwri/(/«i/ (15), which ])ierce8 the great sacs 
sciatic ligament to supi)ly the part^ abuut tlie coccyx ; 2, the co 
Turvi igrhuidin (28), which runs upon tlie great sciatic nerve 
into its terminal bmnches, and appears to be the direct continuati 
of the main trunk ; and 3, tlie anastMiolic brunch (16), which _ 
to the root of the great trochanter to anttatomose with the gluti 
and internal circumflex oiteries and soiuetiiuea with the est 
circumflex in the so-called crucial anastoniMia. 

The veiiu corresponding to the sciatic artery open into the int 
iliac vein. 

The Internal Pudio Artery (Fig. 73, 9) is only seen in 



THE INTERNAL PUDIC ARTERY. 



153 



I over the spine of the ischium, as it wiiuls out of thu great 

ciatic fontmcn below the pyriforraia to re-enter the ixjlviu by 

I leaser sacro-sciatic foiwiieii, above the tendon of tiiu nbturattjr 

iiitfBaii& The itrt«ry is accompanied by its vein and by two nerves, 



Fi«.73. 




Fig. 73.— Aricriei of the buttock (after Hcnle). 



• 6hrtfiilnrfcTv(^upcTfiri«lbninch). 15. 

"■..■-•, ■■ n). 16. 
Ml). 

. ,. .;.!.. irtcry. 17. 

■ Ininti at ({luteal nrtcry. Itj. 
I Infrhor iliwp glutuil artery. 

' fyrifonnii. IB. 

< Olutcu* niinimus. 2U. 

' Pudie «r1fry. 21. 

' Orml Kiltie ncrre. 22. 

• Sfflill Bivro-tciiitic ligament. 23. 

• Qlutcuii medius (insertion). 2'!. 
I*. Sciatic artery. 26. 

AiittSSEiianter. 28. 




Coci ygcnl liranch of sciatic artery. 
Ann.'ttoinatic bnuich of souilic 

urlcTj', 
Great tmcro-scintic ligunient. 
Obturator intcmua and the two 

gemt'lti. 
Extimnl epbini-ter ani. 
Ti'ndoii of obturator cxtenius. 
Inferior ha'uiorrhoidtil artery. 
Inx>rtiun of gluteus maximus. 
ImIuhI tulierasitv. 
(iuadrutuft ft'moris. 
Siimll tnx-hiinter. 
Comea nerri ischiadici. 



154 



THE BCriTOCK. 



the puilic nerve lying to iU inner aide and the nerve to the oh 
internum ••xleninlly. 

A linuich of urtery will be found both at the upper and lowtr 

borders of the <iim<lnitn3. The 



Fig. 74. 



Ml 




up|KT u a branch of either tlu 
i]iterual circumflex or obtuistor 
nrtery accompanj'ing the temloo 
of the obturator exteniun, and 
the lower, which i» more con- 
stant, is one of the terminal 
lirnnches of the internal 
L'uiatle.x artery. These uii 
mosc with the sciatic artery, 
the lower also with the 
perforating of the profunda. 



Fig. 74. — Nenre* of the buttock ind 
buck of the thigh (from HlnchteU 
nnd Lcvtille). 

1. Gluteus mnximui. 
*. GUitcMi^ ineilitis. 

3. (Jluti'ul nrtci-)' mul Bupniorglates 

nervo. 

4. Gluteus mininiui. 

5. Nvrvo to obturator intrmui. 

6. I'ynformiii. 

7. I'udio iiurve. 

8. Smull aoiiilio nem>. 

9. G rent Biicro-scintic li^ment, 

10. Obturator iiUrrnus and gemeUi. 

11. Inferior gluteal nerve &om mull 

irintic. 

12. Tendon of obturntor extemut. 

13. Inferior pudendul nerve 

(Swmmering). 
M. Quadnitus femorii. 
Ifi. Oraeilia. 
Ifl, Great wiiitic ner>-e. 

17. .\dductor mufnius. 

18. Insertion of glulpua miiximut. 

19. United originii of acmi-tendinaiai 

iind biceps. 
'2U. Short head of bicep*. 

21. Semi-nieinhranosus. 

22. Tendon of biceju. 

23. Tendon of semi-lendinosus. 

24. Kxtorniil ]>opliteiil nerve. 

25. Intemiil po|ilit<'al nerve. 

26. C'oniniunii uiis tibuliiris nerve. 

27. Popliteal iirtery. 
29. Gastrocnemius. 
31. Coiumunieans tibiali* nervs. 



THK SCIATIC NERVES. 



155 



The Superior Gluteal Nerve (Fi?. 74, 3) in a branch of tlie 
lumlxi-iiacrnl con\, aiul iiin;i'j,'v>- fri>m tlio pelvU witli tlic tjhitnol 
artfry aWjve tho pjTifoniiiM. It ilivide* into two brnnchd^, which 
occonijMuiy the ilc«p ilivixinn of tlu' nrtiTy iM'iween the gluloiu 
racidiiia and utiniuiUR aud Hiipply tJivMC iuiucU'h, the lower cue 
^oin^ forwnnl tu tlii? tfniKir faM-iiu ffiuoriH, 

B The Small Sciatic Nerve ( Fig. 71, 8) ia one i>f the tuain 
HMMcheit of the sucml ]JrxuN, luul ap{H-an at the tower burdor 
Hf the p> rifoiinis to iH-cniiic the riitaiu'oiu ncr\°e at tho Itark of thi: 
HtiKli- As !«o«n iM it omcr),'!-* fi«iii t)iu pelvio it given rooiirrent 
Btitneous liniiiches to the »kiii over tin- lower piirt of the gliiteiix 
Huuimiii*, and sonietiniex an ivfiruir ijhitnU hntuch to the under 
^brface of the Uiuscle it.telf. It llieti (;ive» off the in/rrifr jiitdcndal 
Btrve which windii U-low tlie tnlierxwity of the ixthiiini to Uie 
H^ritueuni, iiud other ciitnncouit brniiches wliich de»cenil to nupply 
Be back of the thigh, popliteal rvgion and upper half or man> 
H the ralf (13), 

■ Tlie Inferior Gluteal Nerve inoel frequently hoa a dLitinct ari^pa 
Koni tlie Mural jdeMi", and in not very intiiiiiktely connected with 
^Be •niall fcialic : it u the nerve of aup])ly to the gluteus nmximiui, 
H The Great Sciatic Nerve (Fig. 74, 16) in the largest trunk of 
■le luirml plexu", and uppejira ot Uic lower border of the |iyrifoiiui«, 
K' occmionully pierciw the niu«cle. At the level of the lii]>-joiul it 
Hea uiKin the jjosicrior lip of the acetuliuluni, then ruUH upon the 
Hbturntor intemu.s and gi-nielli, i|iiudrutu>i femoiis, iind adductor 
Huignux lietwceli the JMliial tulxTonity and the great trcxduintrr, close 
B> the inner hide of the mtk und le^iKer ir'ahftuter of the femur, 
^kd becoioeii related posteriorly with the nhaft about th* middle 
B the thigh ufyt»-'4liBap]icariiig bcnenth the hunistring inilMolea. 
KFetuilly this W»\-e gives no bronehei* in tlikregion. but the uer\'e« 
K the quodratUH and hi|i-joint are DomeCUiiei) derived from it, 
Kctrod of from the hoitmI jdexun itself. T1>e (loiiitiun of the trunk 
Hiust he rcmenilK.T<'<l in niuking pooterior counter u^icnings in 
Hpnnexion with hif ili><ea>e or after exci.tion. 

■ The Nerve- to the Obturator Internum (Fig. 74, 5) arifus* 
K^ the uplttfjKirt of the sacral plexus, and lenve« the pelvix lie- 
^Mr the pyrijjpiuiK, taking Uie «ame courne an the pudic veswU and 
Kill 11 over tlio q>ine of the iachiuTu, but lying to their outer side. 
FAs it winds into the le*»er foiumen it gives a brunch to the 8Uf)erior 
BuneUna, and then wjiplicM the fibres of the obturator within tho 
Htlvin. 

H I'he Nerve to the Quadratua (Fig. 74) arise* from tin: anterior 
^lrfa<:e of tiie sticml jilexun, onJ pit<$&i with a branch fwm Uw. 



156 



THE POPLITEAL SPACE. 



^ 



sciatic artery, Wnuath the obturator intemiu tendon to supply the 
quadratus and inferior geiuc-llus. It Una against the back of tile 
hip-joint, to which it gives a branch. 

The Pudio Bferve (Fig. 74, 7) from the sacral plexus, is «een 
lying on the Bpinc of the ischium intenmlly to the pudic vessels. If 
the inferior hicuionlioidal nerve should liapjien to arise separstelji 
from the sucral plexus, it will be found accompanying the pudk in 
this position. 

The Poputeal Space. 



4 

K thm 



The dissection of thu jxipliteul space shoidd be mode before 
sicin on the buck of the u]i]>er ])art of the thigh i« reinove<l, so that 
the relations of the parts in the hum may be undisturbed. 

[A vertical incision is Ui be made in the middle line of the limb 1 
the buck of the knee, extending; lor six inches alxive and the xaiu 
disUince below the joint. A transverse incieion at each end of tb 
will allow the i»kin to be fully reflected. A few bnmches of the suu 
sciatic and inteniul cutaneous nerves may be found in the superficii 
fascia, which is to be removed in order to ex]x>se the deep fawia.] 

Deep or Popliteal Fascia. — This is continuous with the fs 
lat-ii, and stl-engtheiied by fibres from the hamstring tendons. It 
stretches across the popliteal space to protect the vessels and lie 
beneath, and is tense when the limb is extended, but is at on 
relaxed on bending the knee. Branches of the small sciatic m 
are distributed to the integument over the space. 

[The fascia being removed, the hollow of the ham will be broogh. 
into view filled with lo(jse fat, which is to be rcnioveil to expose the 
pii]i!iteal vessels iiml nerves. The intenial popliteal nerve and the 
jKiplitfal vessels will appear in the jaiildle of the spaoe, the extcr 
popliteal nerve near its outer bdundary. Imbeddeil in the fat of th 
pojiliteid space are some lymphatic ghinds, and it may be noted tl 
there are no glands in the limb below this point except, perhaps, on 
with the anterior tibial vessels. The bounduries of the siiace are I 
be carefully cleaned, care being taken, «t the lower part, 01 two smi 
nerves and a vein which nm on the tiack of the leg, us well u» 1 
some small articular twigs to the knee-joint ut the sides of the sp 
The vpixr articular aHerits an: to be found ninnini; inwards 
oiitwaws almve the condyles of the femiir, and a thim tKtjgo* branc 
pieixjilig the jtosterlor ligament of the knee-joint.] 

The Popliteal Space (Fig. 75) is a lozenge-shaped cavity at I 
back of the knee, which in the dissected state extends for some 1 
tjiiice above and a little below the joint. It is continuous above witi 
Hunter's canal through the opening in the adductor niagnua, 1 



THE POPLITEAL SPACE. 



157 



• with tlicdc'cp iuU-nnusculnr ipares of the leg. It* nppnrpftrt 
la boondol atUrmalUj by the l)iccp« ; %nltrr)alt)j by the aildiictur 

Fie. 76. 




more raperfimlly by the senii-meuibmnoau* and 
«emi-t('ndino(iiu. Ita lower part hot one of the ileaby 



Tig- 76.— The (Hiplitt;*! tfucv (froin ITiurmity ColK'ge Miuoum). 



Small aciatic iirrrr (turnrd up) . 
Ulcap* oiul cxlcmnl |>uj>Utcal 



Pufl.^ 



'Ill nerve. 

.ulKXUI. 

iTcin. 

Fttitrninl urtifuUr nrl'Tjr 
' I hnmch of obtun- 



9. lirBpilui. 

10. NuiH-M-iui I'vtrriinl nrtiiuUr lUrtvr)' 

uiiil iirltr-ulur iievvi*. 

11. SurUJiiun. 
r.'. I'laiitiiu*. 

li'i. (i;!-! r--- 'I'M T' Itmil. 

H. G>i hmil 

18. C" iierTK. 

16, C'l I luTif. 

17. K- win. 
10. luic .-, .. - ucrve. 



158 



THE POPLITEAL SPACE. 



Fig. 76. 



necle 
athH 



heads of the gastrocnemius muscle on fttch side, and on the 

side there is, in addition, the ^iiiall plantai-is muscle. 

The Jtoor of the space is formed at the upper port by the triong 

popliteal surface of the femur l>e- 
tween the diWsions of the IIdm 
nspcrn ; next by the posterior lign- 
ment of the knee-joint ; and at the 
lower part by the popliteus mnecle 
and the fascia covering; it. 
popliteus can only be seen when I 
iuuer head of the gaslri)cnemiu» is 
ilivideil near ita origin and turned 
down. 

The Internal Popliteal Narre 
(Fig. 75, 4) i» the most superficial 
of the import^uit structures in the 
ham. It ia the larger division of 
the great sciatic nerve, oud piuiei 
down the unildle of the space, dis- 
appearing beneath the gnstrocnt^H 
mius muscle. It crosses from tli^f 
outer to the inner side of the jHjpli 
teal orterj-, which it accomjwinies to 
the lower border of the po])litea 
muscle. Its branches ore (I) 
tieiilar, three in number, whid 
pierce the posterior surface of 
knee-joint, and accompany the twd 
internal and the azygos articu 
arteries ; (2) muscular to the gaa«J 
trocnemius (one to each head); 
>ioleU8, plautaris and popliteus j 
the branch of the popliteus 



Fig. 76. — l)i>ep dinection of tbo poplitviU 

1. Adductor ma^iu. 

2. Vaatus externu*. 

3. FopUtctl vein. 

4. Greut sciutic nerve. 
8. Poplitoal artery. 

6. Short head uf biceps. 

7. Inleranl popliteul ncrrc. 

8. External popliteal nen-e. 

9. Vnstii» intern uB. 

10. Lung hend of biieps (cut). 

11. Superior iotemal articuUr uter}*. 



spare (from Hirsehfcld und LereilU]! 
I'l. Outer hcnd of ^:i>troi'nomiu>. 

13. Tendon of Henii-meinhriinoAiu. 

14. Communicans peronei nerve. I 
16. Inner head of gsatrocneniiu*. 

16. Soleus. 

17. Inferior intemid articular arttry. 

18. Gostroenemiui. ■ 

19. Popliteus. I 

20. External saphenous vein ant 

nerve. 

21. Tendon of plan taria. 



THE POPLITEAL ARTEUY. 



]5» 



iar in thul it rui<* upon the posterior aurfuoc of the ntnxcle, then 
upwnixU iiiYiaiid it< lowcv lionlrr to mtcr it» imtiTior or 
' ciirfaw ; lUid (3) iho rricnutl Mjilumout nrrvt * or riimiw eam- 
\inioitu tHiMi*, which lies ill the groove botwi'cn the lieailit uf 
gti^tnxneiuiuii (MoiiiL-timcji beueutli ii few uf it« fibnv), and will 
trac4M.l in the (lisM'ction uf the back of the leg. 
The External FopUt«»l I'r Peroneal Nerve (Fig. 75, 3 ), the 
Uier division of the griat sciiilii-, is iiltogi-lhc-r under eovcr of the 
ccps at the upjwjr jiart of the spaci-, but becomes visible close to 
> tendon iicur the heml of the libiiln. It give* a communicating 
ancb (niwiM cmnm 11 nirinu jmoiiei rtl jUiiUarin) down tlie Iwck of 
I^ to join the e^leMiiil BUpheiioUH nerve, wid two or three ttrti- 
' bnuiches. Of Ihew two, nomeliiues arising to^jether, iici'onii>iiny 
I txtemul articulnr branches of the popliteiil urtery ; the othi^r 
(the reciimtnt Artic\ilur) winds to the front of the joint with the 
current branch of tlie anterior tibiiU artery. An vxt«ma1 cut«- 
Mw uvrvu to the outer side of the leg arigtvi either from tlie 
Klvnuil jiopliteal ilnelf, or moi-e frequently from the cominuuicanH 
l>ulari8. 'I'he uiatic nerve may l>e found ul the upjK-r utigle of the 
ace when its bifunuttion m unuoually low. 

The Popliteal Artery (Fig. 75, 8) in the continuation of th« 
artery, and extends from the opening in the adductor 
to the lower border of the poplit«'U« muscle, where it 
idea into iinierior and pot<ti'r)or tibiidH. It lien near the bottom 
the {Kiplileal apace, M-puruted fiiiui the back of the femur by a 
piyer of fat of ulmut a ijimrter of an inch in thickueux (an imjKirlunt 
ct to ririucmber in connection with rupra-condyloid osteotomy) but 
; is in direct contact with the jKjsterior ligament of the knee, and 
be poplit4<UD luiiM'le and fatcia. It hoa a direction from the inner 
it ol llie femur to the middle of the leg. Its vein is first to it* 
Iter tide iheu cnwxes it Kii]H'rficially and lies slightly to ita inner 
idc below, wiiilsl the internal pojiliteal nerve is still more super- 
r.ial and al*o crosses the artery from without inwahlx. The 
aeucemeiit of the jK)iditeiJ artery in under cover of the Bonii- 
ttOtiu*, the midiib' of the ves-sel Ls in the hollow of the ham, 
ft«d by mUlH.'le^ and it.e lower j>art U beneath the gaiilroc- 
aius and plantariit uiiisclcs. A branch of the oblurulor nerve 
»r be fonml on the upj>er part of the artery, and traced to the 
ck of the knee joint. 
The Branches (Kigs. 75 and 76) of the popliteal ortery are 



• The tenn Exlorunl Suiiliciiuun i> ►oroetinic* limited «o the nerrn furraeil by 
lie iunctioa of Uio runiinunic.m« tiliinlia willi tUc communicoua tibubim. 



160 



THE POPLITEAL SPACE. 



luprrioT and inferior mutcular to the ImniBtrings and muscles < 
calf, and articiilnr to the knei'-joint. 

1. The SujifTirrr Miuciilnr branches orise from llie upper pMt< 
the ortury, and are distributed to the adjacent hamstring rail 
anastomusing with tlie perforating and tenuinal branches uf 
profunda. 

2. The Articular branches are five in number, vis,, two superiii 
two inferior, and one azygos. 

The superior artcrien, internal and extenial, arise judt above I 
condyles of the femur, and win<l horizontally inwards and oulv 
to the front of the kiice-joiiit, to supply it, and to anastomose wifl 
one another, with the anastonxotica nmgna and the descemli 
branch of the external circunitlex and the other arteries alx^ut i 
joint. The external paRSts beneath the tendon of the Viice}i3, 
internal beneath those of the mlductor mogniis and inner hamstring 
The inferior articular arteries arise on the popliteus. The intis 
(the lower of the two) runs obliquely downwards and inwards brio 
the inner tuljerosity fif the tibia following the upper btinler of ti| 
popliteus and jiassing heneath the long portion of the internal lateu 
ligament ; the r,^^ ni<r/ passes horizontally outwards altogether tiboi 
the head of the fibula lietween the external lateral ligament and i 
semilunar tibro-cartilage to the front of the joint. The azyijot ar 
about the middle of the artery and pierces the posterior ligament wilJ 
the obturator nerve to supply the aynoviol membrane and cruc 
ligaments, und to join the other bnmehes. 

3. The Itiferiiir iniuciiliir branches (sural) are distributed to 
mascles of the calf, 

Surgery. — The popliteal artery may be compressed by I he ban 
or a louriiiiiuet The operation of tying the pcipliteal artery fd 
aneurism is never performed, but it might be necesj-ury to 
the vessel if wounded ; in wliidi case an incision to the inner side I 
the Bjiace would enable the opeialor to reach the middle of the orb 
without injury to the nerves, or it may lie readily accomplishcl 
through a 3-iLich incision in the middle of the space. 

The close relation of the artery to the posterior ligament of ' 
knee should be remembered in excision of the joint ; and it is tli 
Bepanition of the veswl idiDve this point from the popliteal snrfoi 
of the femur bv a )ind of fal that has rendere<l feasible the operatia 
of supra-condyloid osteotomy. The clone contiguity of the extern 
popliteal nerve to the biceps tendon and external lateral ligamen^ 
cxiiose* the nerve trunk to some danger in arthrectomy for extensil 
tubercular disease of the knee. 

The Popliteal Vein (Fig. 70, 3) is forme<l by the junction 



THE BACK OF THE THIOH. 



101 



The Back of the Thioh. 



erior aiitl poat«rior tibial veiiu at the lower Ixitdi'T of thti 
Ul The vein is superficial to the nrtury, iukI lies slightly to 
T »ide at the lowor fiart of the Rjwce, but croaso* to the outer 
Dve. Itiiicci^' . iiw corrcdfKiniiiiig to 111"' liniiichra o( 

ly and, at a v. nt, tho nttrrmd «ii[iheii<iiij> rriii, wliid 

thl> back of the k'^ U'lu'cfii the heiuU of the ;;ikHti'<K'iK'iiiiii^1 
htu it Like the iiU]ierliciul feiiioml veiu it i» vonielituda^ 
Ited by two venie coiuite*, one of which is much larger than 
►r. 

: or five rnnall lymphatic ylamU nrc ]>lnce<l clost- to the artery. 
Iceivc the »ui>orficial lyui|ihrtiio( occompanyiiiij; the uxtomal 
U» vein from the back of tin? Icig and heel, iiml ileeji lym- 
oc/conipanyiug the vena) coiuites of the anterior and tibial 
from the bones, iniwcle*, &c The eifercnt vc«eU end in 
[» femoral glandfl. 

^Bn left on the iMick of thi- thigh ix to lie reiiioviij, and xoniV'J 
puichca of the. giiiull sciiitii' m^ve nmy be fniinii in iln; ^ulx 

W ' : the norvo it»elf will l>c Been on rcinoviii^' the ileep ' 

> I the luuuHtriug uitmclo iitnl the (p-eat sciatic nrrve, 

< l.J 

Bamatring MusoleB (FigM. 71 and 1\) are three in nuui- 
., the biceps on Uie outer itide, and the Henii-toniliiiosu* und 
imbmnoNUB on the inner side. The (rnicili« iiinl gartoriuB 
llg<) l>e regarded os inner hamstrings. The liirejM ami scmi- 
»uii, which arise in orjnuiioii, an' aupiTfirial to tln' xfini-iiiem-, 
t^ nvar th<- tuU-r ischii, atiii the Hi>iui-teiidiiiOKii>t iiiiiintaiil 
Mioii tv the (ie»ii-itieiubriUK«UH throuj;hout. Tin' nhorl head 
biceps will be found on the outer aide of the lower jiarl of 
Mr. 

BiaepB (Pig. 74, 19) or out<rr hnmittring aritt$ by itn long 
Dm the tuber ischii, in eomuion with the senti-tendinoHiuJ 
Ri the great sacro-sciatic ligament, witli the tibrca of which 
direct continuity. It croases the grwU aciatic nerve and, 
rging from the seiui-membnuiosiLH in the lower fourth of the 
urm» tlie outer lioiiuJary of the pojditcal 8]mce. The ishort 
10), which is lleshy, arisff from tJie outer lip of the linea 
nearly on high tti< the insertion of the glutcuM maximus, ami 
I outer division to within twoinche-s of the comlylc, and from 
PmJ intfrmuscular septuni. The two heoiln having miiti.vl 
lower end of the femur, tlie muscle is iiiirrleil into 



162 



THE BACK OF THE THIGH. 



the bicipital tu1)eroBity on the outer side of the head of 
fibula, into the fftscia of llie leg, mid by n slip which passo 
front of the tibio-fibulnr joint into the adjacent portion of tb« 
tibial ttibcroclty. The tendon splits to enclose the lower eiul of 
the long I'Xtenial lateral ligament, from which it is aepomted by « 
burm (Fig. 75, 2). 

The Semi-tondtnoBtxB (Fig. 74, 19) arue* by tle»hy fibres froa 
the tendon of the bic«}>ii, and in common with it from the irnur 
))ortion of the back of the tuber ischii. It forms one of the inixr 
boundaries of the popliteal s))acc, aiul ends in n long sleiKler !• ■ 
which lies on the semi-membranosus posterior to the gracil 
passes to be inMrted into the deep fascia of the leg and into tli 
below the inner tuVierosity, lying tlicre beneath the tendon "i 
sarloriub and lielow that of the gracilis, and surrounded by a ''Ww 
common to it and the two muscles named. Its fibres are crossed ij 
a tendintiHs intersection. 

The Bemi-membranoBUB (Fig. 74, 21), though one of tiie 
internal hmuiitriiigs, is external to the bicepe at its origin. It itritn 
by n strong tendon fmm the outer and upjier part of the tuber iscLu. 
and passing beneath the origins of the biceps and semi-tendiuceiLS 
from whii h it is separated by a &ur<a, .spreads into a Lroo^l tendua 
from which the muscular fibres arise to form a thick belly that ex- 
tends nearly as low us the knee. It is inaerUd by a short stton^ 
tendon into an iuipres.'-ion nt the back of the inner surface of tbt 
intenud tuberosity of the tibia and into a horizontal groove iu front 
of this, beneath the interaal lut«r(d ligament of the knee. It gins 
otl' two expansions, one running upwards and outwards to tlit 
femur above the outer condyle, forming the oblique fascicultu J 
the ]>oslerior ligament of the knee-joint, luid the other to cover the 
popliteus muscle (Fig. 8£, 9). Its tendon is se^Mirated from Iht 
innei' head of the gastrocnemius and from the knee-joint by a bum 
that frequently communicates with the arliuulution ; uiid a secouil 
burm will be found between it and the internal lateral ligaineut 

Aclkm. — Tlie hamstring muscles Hex the leg upon the thigh, and 
extend the thigh u]>on thei>elvis, as iu walking or running, aad whei 
the knee i.s ilexed the inner hanistrings with the i>opliteus gracilij 
and sartoriiis rotate the leg inwards (pronation), and the biceps rot^to 
it outwaiJfi CMijiination). When the knee is extended and the Irg 
is the fixed ]iuint, they extend the trunk and aid iu maintaining tlie 
erect jiosture of the IxKly. They also assist the glutei in tvgulating 
the flexion of the tnuik, by controlling the foi-ce of gnivitation. It 
the thigh )<e itcjied while the knee is extended, the hamstrings ami 
great sciatic ner\'c become very tense, and when great forte is uad 



ita^M 



THE HIP-JOINT. 



163 



Tuctores may be rui>ture(l. Hence the knees must always 
te llexeU when the nubject is placed in. the lithotomy position for 
diiMction of the perinoium. The hamstrings ure supplied by the 
great sciatic ncrre. 

The Oreat Sciatic Nerve (Fig. 74, i6), sec page 155, is con- 
tinuetl from the buttoi!k and, after leaving the quailratus femoris, 
lies on the posterior surface of the adductor mii>!niis, to which it 
giyea a branch, and pa«se» beneath the bicep-', sii{)]dyiiig this ami 
the seiuimembraniisus and eeniitendintwui-. At a variable point, but 
generally alniut the middle of the thi|.;b, the nerve divides into the 
internal and external iKj])liteHl tniulcs, which have been already ti-accd. 

Beneath the sciatic nerve will be seen the iwsterior surface of the 
•ddactor niagnus, and piercing the muAcle at various points close to 
its insertion are the terniination.s of the perforatiitij iirUriai from the 
profaada uid the terminal branch of the artery itself, which are 
now seen to supply the hamstring muscles (v. p. 142). The terminal 
bltmch of the internal dreumjUx arttry, between the fjiiadratus and 
the adductor magnus, can now also be more fully traced out. 

The PoPLlTKCS muscle is described on page 172. 

[Before the subject is re-turned, the gluteus minimus, pyriformis, 
■nd obturator intemus should be turned aside, anrl the back of the 
hip-joint dissected, but the joint itself should not be opened. 
Opportunity should now be taken to trace the retlected tendon of 
the re<'tU8 femori.s arising from a i'(mf;h irujiression above the aceta- 
btilam. When the subject is replaced on its back, the front of the 
joint is also to lie dis^^ecled by removing the psoas and iliacus 
•nd the remains of the pectineus. After learning the external 
ligamentK, the joint may be opened and the intracapsular structures 
examiue<l. The limb may then be removwl.] 



The Hip-Joint is the best example in the body of an enarthrodial 
or lj«ll-Aud-«ocket joint, and ia furnished with a powerful capsular 
ligaiuent, besides other articular structures. 

Bdativnji. — Ttic hif>-joiut has in front tlie united psoas and iliacus 
«nd the outer edge of the jiectineus ; and more suiierticially lie the 
rectus, the femond vessels and the anterior crural nerve ; lifliiiicl, 
are the pyrifonnin, obturator intenms, and gemelli, the obturator 
extemus and ujiiicr tibres of the r|Uadratus femoris, with the sciatic 
nerrea and vessels lying upon tliera clo«; to the posterior mai^gin of 
the acetabulum ; iiliorc and rxlenuilty, lie the gluteus minimus and 
the ili>^>-(rochanteric band ; and helow and intenuilly, are the tendon 
of the obturator extenius and the pectincus (Fig. 77). 

The liijamenti of tlu hip-joint are of two kinds, those which com- 

M 2. 



164 



THE HIP-JOINT. 



plete and deepen the socket — ^the transverse and cotyloid, and tiiott 
which connect the two Ixinea — the cnpsulnr and the round. 

The Capsular Iiigament ( Fig. 70, i ) is attached to the margin (rf 
the acetalmlum, and to the transverse ligament above ; and aurroandi 



Tig. 77. 




the upper end of the femur below. Its njifier attacliment followa tlo 
acetabular border, but extends beyond this to the anterior inferior 
iliac spine above, to the body of the ischium at ila junction with the 
ilium liehind, and to the body of the os pubis and o)>turat(>r externui 
foacifl in frout. Its lower attachment jiasses around the femur, from 
the tubercle (tuberculum colli superius) along the spiral line to a rough 



Fig. 77. — Vertical swtion thinujfh the hip-joint showing the heiiil of llie feniur,tk( 
vap«ulc, and the muscle* eurrouriding the articulntion (ma<Uli«l from Hcnk]. 



1, 2. Gluteuii tnediiu. 

3. Obturator intvmuii and gvmcUi. 

4. Ilio-fenioral bund. 

5. Ischio-fc'inorul baud. 

6. Hectus femoris. 
Uundratuj femorii. 

LS. Iliacui. 



9. Semitendinoaus and bicejM. 

10. I'siWK. 

11. Si'iiiimcmbranoiius. 

12. I'uhci-fcmoral band. 
14. Obturator oxteraui. 
Hi. Symphysis pubis. 

F. Section of head of rermur. 



THE HIP-JOINT. 



166 



Tig. 78. 



elevation (t«bercu1iiiu colli liiferlu*) at the lovel of tho lower p«rt of 

the ]ira««r li-ochiiiiUT. Tlicjioe it ninn up thu tiiiJwtriVioil capviilnr 

lini.- ill fn^iit uf the luttrr i-mineucx-, nnil itdbm-k the uiiditle of the 

W-k uf the urci to rcacji tlio iligitjil foAxi lunl Uie sui«rior tulj«<rcle. 

It is >jnt fcrbly coniii-ct<-il t(i tliu smooth ixwterior jHirtion of Uie 

!>iit is Ktrongly iittiiolied elMwbere, rdiI sontu tluep librui aro 

1 into the fnmt of the neck above Ihi- Bpinil liuf. 

Three pi'Wi'iful Initiilx, funuinK ii juvrt of tho o«iwiiIe, are ililfcr- 

cntintcl, uuder the nuuie.i of ilio-fuuinrnl, iBchio-foiuoral, and piilx)- 

fetnorul li^uineuts : these arc 8i-|Niriitotl at their acutubular attach- 

njcTit*. hut art continnoiu (it their feiiKiral 

iuBcrtiunii (»e« Figs. 77 lUul 7h). 

The ilui-friiK/riil Innii pu»*e» from iJie lower 

jiort <if thii anterior iiifenor iliau B])ine and 

!lio notch bt'Uiw it, to the Mi])cri(ir 

',>■ of the nei'k, und to the F.pintl line ii> 

lar aif the inferior tiilK'itlc. It* tibri'* hit 

often cleft np^Misite the niiddlu of it^ lowvi 

hment, ami the IuithI then iixiiuiueii a 

resenihliiig an inverted V or Y (whence 

name Y-«tia|>«d ligumenl »onieiiniei> given 

the Htructure). It i» of tvniarkuhlc strength, 

oud limit* the movements of extension, od- 

daclion, and exti-nial rotation of the femur. 

The itcliio-friiiornl IhiikI is u broml fitxeicu- 
lu- • from tlie Ixvk of the iwliio-pubic 

jii; ive the tul>eri>»ity, to liefomo iittoclied to the anterior 

>ii(>t,iioi ttiigli. of the great tniehuntcr, lilenilin;,' thcry with the 
unt^T i>uit of the iliu-femuni] l>und. It limits internal rotation of 
the feiuur. 

The pulio-frmnrat band ii|irings fr«)m the puliic bono in front of 
the iicetatmliim, und from the obturator eiternuu fusoia, and Iwcomea 
attached Ih-1ow to tiie tnU'iviiluin colli inferiiu, joining nt this jKiint 
the inner jiart of the ilio-feniotaj band, and to the unnamed ca|j«iilar 
line running fium it to the inner border of the nock. It liinita 
the uiovement of aliiluclion. 

The portions of the capsular ligament between the three bandaJ 
relatively thin, the weakest jxjint lying between the iaehio-l 
il and jiubo-fcmor.al biinds over the head of tlic femur, and 
!i ajK'rturc of cuiumuuication is sometimea found between tho 
nviiukial cavity and a bursa lieneath the ilio-paoaa muscle. Th*i 





w 



Tig. 78.— The ilio-femonil or T-Ugamrnt of liigelow (from Bryinf). 



166 



THE HJP-JOINT. 



caprole is, however, strengthened hy the muscle, and some fibrei of 
the iliacus commonly take origin from it. The relatively feeble 
l>ortions of the hack of the capsule lie aliove and below the isdiio- 
fenioral band. 

MovemtnU. — The hip-joint mlniits of the movements of fleiion, 
erteufsion, alKluction, adduction, rotation and cin'tuiiduction. .' 
is performed by the psoas and iliacus, the jwctineiis, the udu . i.. 
longus and brevis, the tensor vagina) feuioris, the anterior tibnrs of 
the glutei medius and minimus, and by the rectus ; exteiuioH br 
the gluteus maximus and itosterior fibres of tlie other ^'lutei, md 
less directly by the Immstrings and adductor niagnu». It b 
adducttd by the three adductor muscles, the pectineus, the luwei 
fibres of the gl\it«u8 uiaxinnis, the obturator extenuis, the qii ■ 
femoris, the hamstrings and the gmcilis ; and abdnded by tb^ 
medius and minimus, pyriforniis, and tensor vngino! femoris , ami 
during Hexion also by the oliturator internus and gvinelH. Rotation 
mihcardt is effected by the gluteus maximns, the jHislerior fibrt* of 
the medius and minimus, the ilio-jisoas, the pyrifonnis, the obturalors 
and gemelli, tlie cpiadmtus I'enioris, the sartorius, and the three aildnc- 
tors J rotation inuHirdt by the anterior fibres of the glutei niediui 
minimus, ami the tensor vagina; femoris. 

The so-called movement of exteiution is really a restitution to 
position of station after flexion, ami is arresteil by the tension of the 
ilid-femaral band when the thigh reaches the veitiaxl line in the 
standing position. Add net imi h in Mkn manner little more than* 
similar rfstitiitiun after abduction, and is checked by the ilio- femoral 
band after about IS" of movement of the feuioral axis beyond the 
vertical line. Flexion is very extensive, and is checked during life 
by the i-esistance of the extensors. It is greatly restricted by the 
tension of the hamstrings when the knee is extended, ajid if violence 
be »i8ed under these circumstances the muscles and sciatic nervei 
may be tern. AMuHion is limited in most adults to 45' or 50' 
by the pubo-femoral bund, but in children and acrobats the sep 
tion of the two limbs may be contiiuiwl until the perinfeum coi 
in contact M'ith the ground. Intermtl and external rotation atv V( 
limited, unless combined with tiexion, the former is checkctl by 
iscliio-femoral band, the latter by the ujjper portion of the ilio-femoi 
band. It will thus be seen tlial in the position of station, when 
the boily rests upon one leg, the hip of tliat limb is almost com- 
pletely fixed, so far as movements of extension, adduction, and 
external rotation are concerned, by the passive tension of the il 
femoral band. 

The Transverse Ligament consists of fibres bi-idguig aetoae 



lUC- 

UU ■ 



THE niP-JOINT. 



167 



the cotyloid notch, lilwidinK intimntcly with the cotyhiiil ligament, 
anil giving attachment in ihix pofiitiiiii to thi< cu]>«iile. It ronvcrtj 
the notch into a foreman, which tMuiDuiitk articular vuiwalnnnJ nerve* 
, ii occupied liy n niuMi of fut (laaiiiiig into the Uittoni of the coty- 
. dv]itvMiiou uud into the lii^'atnvntum tereii. 
lie Cotyloid Iiigament (Fig. 70, i) in a lihro-uirtiljf^inoiu 
■cturc re^cnililin^ the glenoid li^oini'nt in the Ahoiilder-Juint. 
Bugulitr on section, pn^scnting two free »urfncf« covered 
rial nivmbmne, anil an attached gurfaco, lirnily tixeil to the 
biai^iih of the acetabulum and to the tmnsverso ligament where Uie 
Imue i» deficient. 

^e Iiigamentiim Teres (Fig. 79, 3) cuniiliitD of a fold of 

Fig. 76. 





k 

^^Pbviol nteuibmne retlrct^-d from the margins of the cotyloid 
mpTvasion (fovea acetahuli) and notch, and from the tnuutveiM 



Fi(r. 79. — UlfMnonts iif the hip-joint (fTom Suppey). 



^■Jlio-femoral band of CAptular liga- 
^H mcnt, cut acnxa. 

^■Jux^ .-amentum tere* 

^F f the femur. 

I _. . 

T. Atlmlinicnt ul capculu lig&mcnt 



to the back of t)ie neck of the 
femur. 

8. Neck of the femur external to 

uttachment uf uajuular ligu> 
meiit. 

9. Oront trochnnter. 

lU. I'lt ui) tile Kn-iit Iroulinnter. 

11. Small troi-hniitrr. 

12. I*o«tcrior iuter-ttoclunterlu Une. 



THE BACK OF THE 



liguiuent, to the cHinplv (fovea capitifi) on the head of the fejuax. 
It encloses two (ibrous bands, and some iidipose tissue continuour 
with that lying at the bottom of the fovea and filling the cotjloid 
fommen ; tlje fibrous bonds, to whicli the nonie " li^jamentum 
teits " is souu'times liaLit«d, are attached one on each side of the 
cotyloid notch, the stronger slip coining from the posterior iii;ii^i;i. 
and both pass to the head of the femur. Tlie use of tliis stju. ! : ' 
is very doubtful. It becomes tense during flexion with eiteniiil 
rotation, but in miuiy cases is so feebly developed that it could oiler 
no serious resistance to a force cajiable of producing dislocation. 
It contains u small vessel which passes to the head of the femur. 

The tifiiorinl mtmbrane covers over the inner surface of the 
capsular uud cotyloid ligaments, and is reflected on to the neck u( 
the femur and into the cotyloid depression, covering the fat at the 
bottom of the fossa and passing to the fovea capitis of the femur 
as the sheath of thf ligaiiicntum teres. 

When the liganientum teres is destroyed by disease a communics- 
tion is opened up between the synovial cavity and the deep inte^ 
muscular spaces of the thigh by means of the cotyloid foraiuen, and 
pus may escape from the articulation at this point. 

The fat occupying the fovea acetabuli and cotyloid foramen serret 
to equalise the inti'a-articular pressure, and may be seen to bul^ 
thi-ough the foramen or to be drawn into it during moveuenta of 
the Joint. 



The Back, of the Leg. 



1 



[A vertical incision through the centre of the remaining portion ( 
skin on the liack of the leg, joined by a short transN'erse cut at the 
heel, will iwrmit the i-etlectiou of the skin to each side.] 

The External Saphenous Nerve (Fig. 80, 8) (communieal^^ 

tibialu) will be found piei-cing the deep fascia of the leg about half- 
way down tlie limb, to join the coiiuiuinuant fibularu (4), which 
becomes cutaneous near the knee. The nerve thus formed ruM 
along the outer side of the lendo AchUlis, to pass behind the 
external malleolus to the outer side of the foot and little toe. 

Tliis nerve or the external popliteal gives off one or more 
fxtemal cittaiicoun branches to the outer side of the leg. 

A branch or two of the internal sapli4mous veiTt (7) may l>e found 
on the inner side of the back of the leg. The termination of the 
iniiaU eeiiitic nen'e may also be seen at the middle of the back of 
the leg. 

The External Saphenous Vein (Fig. 8l», 6) arises from the 



THE GASTROCNEMIUS. 



169 



outer ride of the dorsal venous arch of the foot, and passes hehind 
the external malleolus close to the external sBphonous ner\'e, thence, 
mnaing uj> the centre of the leg, it pierces the deep fascia at the 
point where the coinniiinicaiis tibialis ner\'e emerges, or nt the level 
of the popliteal s]Hice ; it has been already traued to the popliteal 
rein. It is often joined to the inteniul saphenous vein by a large 
branch which leaves it rinse to its termination. 

The £xtemal Deep Fascia of the leg is continuous with that 
of the thigli. It receives ruinforcenients from the hamstring muscles I 
■ad give* origin to the libres of the tibialis anticus and extensor 
lODgtis digitorum in front of the leg. It ja adherent to the jierios- 
leuiu of tlie subcutaneous surface of the tibia, and from its deep 
inrface pass two principal intermuscular sept.i, one in front of and 
one behind the peronei longus and brevis, liesides a smaller septum 
between the extensor digitorum longus and the tibialiii atiticus. 
Beneath llie gastrocnemius will be found deep fascia! investmenta, 
one for the popliteus, moinly derived from tlie teiidiin ol llie semi- 
menibnuiosu^, the other, beneath the soleus, for the flexor longus 
digitonim, tibialis posticus, and flexor longus hallucis. Near the 
ankle this $ul>soleal intermuscular fascia and the anterior portion of 
tbe external deeji fascia Itecome continuous, and fonn the annular 
ligame&ts which bind down the foot tendons to the tibia and fibula. 

[The deep fascia of the leg is to be removed, except near the 
malleoli, where thickened ]>orltons {tassing on each side between tliat 
hone and the colcAneuni, CiiUed the internal and exti'rnal annular 
ligaments, arc to l>e preserved. The muscles of the calf are then to 
be dissected, after being put on the stretch by 8U|i]iorting the knee 
and drawing the toes towards the front of the leg.] 

The QastroonemiUB (Fig. 81, 4), the superficial mu-scle of the 
colt, has a double-hca<led nrviin from the back of the femur 
immediately above the condyles, the origin of the outer head extend- 
ing into a little depression above the back of the popliteal groove 
upon the external surface of the outer tuberosity, while that of the 
inner head runs upwards for altout nn inch along the internal 
•upra-condyloid ridge. A bursa, sometimes communicating with 
the knee-joint, lies upon the bock of the caijsule beneath the inner 
head and the tendon of the scnii-membranosits. This, if enlarged, 
may overlap the popliteal artery and simulate jKipHleal aneurisni ; 
and it may give rise to a swelling in the ham in synovitis of the 
knee when the synovial and bursal aivities are in contiiuiity. 
The two heads (with the jjlantaris on the outer side), are the lower 
boundaries of the jxipliteul sj^ioce, and unite to fonu otm \ai^'6 



170 



THE BACK OF THE LEG. 



niusde, the fibres of which fiid about the middle of the leg in a 
broAd tbiii tendon that is joined anteriorly and laterally by the 
8oleu8. The conjoined tendon eoutrai-ts near the hei-1 into tb« 

thick rounded leiulu Achillu (6), wliuh 
^'S- 80. expands again slightly, to l)e iiu'^t-d 

into the middle part of the posterior 
fiirfnee of the calcaneuiii, a burta in- 
U;r>'enin8 between it and the upper 
part of tbU surface of the bone. 

[Tlie inner head of the gastrocnemiiu 
has previously been cut ; if the n- 
uiaiiiing head be now carefully divided 
near its origin, and the mu.icle tiiraisl 
down as far as pos.sible, the plani«ri» 
Hint «o)ens, with the popliteu.s covcif) 
« by its lascirt, will be brought into view] 

The PlantariB (Fig. 75, 12) ariMi 
fixiiii above the external condyle of 
the lemur and from the external supn- 
eoudyloid rid^e for about an inch, tfali 
muscle lying internally to and abo» 
the outer head of the gastrocnemin 
lu llesby fibres are about three imrh 
long, but its tendon is the longest id 
the body and is very slender. It 
placed between the gastrocneniiu* 1 
Boleus, and crosses obliiplely to 
the inner side of the tendo Achillis, hj 
the side of or in common with whici 
it is inieiial into the os calcis. It 
homologous to the jialmaris loiigus i 
the upper exti-emily, and ia subject I 
like variations (p. 51). 




Fig. 80. — Supt'rficiiil nervenof the buck of the 
leg (frtiiu Hir^i'lifelii and Levcilld) 

1. Internal poplilcal ncn'e. 

2. External popliteal nerve. 

3. Intemnl •apnenoiu vein. 

4. NervuB commuuicana dbularitf. 
6. Nervus communicuns tibialis. 
6. Extcniiil iiiiphfiious vein. 

Bninch of Interuul saphenous ner^'e. 

£.xtemal ta)>henouo nerve. 

Cttlcanean bnuicli of posterior tibial oem. 



7. 
8. 
9. 




i 



THE SOLEUS. 



171 



Boleiia (Fig. 81, 5) is tendinouB on it« surface, and between 
it and the corresponding tendiiKius expansion on the (ieep Biirface of 
the gastrocneniius is u i)uantity of loose areolar tissue. It arises 
from the oblique line of the tibia, from t!ie middle third of the 
inner bonier of the bone, from the posterior sur- 
bee of the head and upper thinl or more of tlie ^'S- ^^• 

ihaSt of the fibula, from the inteniiusciilar sei'tnni 
between it and the peroneus longtia, and from a 
t^^ndinuiu arch between the tibia! and tibular 
origins over the vessels and nen-es. The fibres 
end in a broail tendon, which joins tliat of the 
gastrocnemius below the middle of the leg to 
form the tendo Achilliii, the iiiaertum of which 
has been Keen. The muscular fibres are inserted 
into the deep surface of the common tendon to 
within two inches of the heel. 

By dividing the fibres of the soleus vertically _ _ . 

and with care, a tendinous eximnsion on the ' ■■..' 

deep surfaci- of the muscle will be brought into 
view, which stretches across the deep nuiscks 
and the posterior tibial vessels and nerve. Tlii.s 
deep tendon is an important guide in the opera- 
tion nf tying the posterior tibial artery, and 
muitl be divided to reach it. 

The muscles of the calf are plantar flexors* 
o( the foot, i.e., j>oint the toes, the gastrocnemius 
and plantaris, in addition, flexing the leg upon 
the thigh ; or, when taking their fixed point 
below they may act uj)on the thigh. They are 
nj/plial ijy the infernal pojiliteal nerve, a Kepa- 
nite branch pa.<ising to each head of the gastro- 
cnemius, and the soleus receives an additioniil 
bnnch from the posterior tibial nerve. 

The form of clul>-foot known as ' talipes 

Vi|^. 81. — Superficial miuolei of the back of the le^; (ftom WilBoD). 

, Tmdon of birfpa . 7. Tuberoaity of o» rtiluia. 

, Trillions of inner haniHtriiig8. 8. TcndniiH of the puraneui lon^iu 

, roplileni apace. iiiiil brevis. 

4. Gastrocncmiu*. 0, Tendons of the tibiiilis posticus and 
i, 6. Soleuii. iexur longus dij^'itoruai. 

, Tendu Acbillis, 

* The temiH tlcxion and extension ra applied to the ankle are Afiplied in oppoBtte 
I bj difl'ervnt uiatomistK, and it is hctioe desirable to avoid their use alto- 
" UoTsil dcxion " uud " plontur fi«xion '' are sclf-cxplunuturj. 



172 



THE BACK OK THE LEG. 



equinus ' ia oasociated with contraction of the muscle* of 
calf, ami division of the tendo Achillis is piiictised for 
relief. 

[The plantaris ia to be divided and tlie soleiis cut near ita ntti 
ments to the tiliin nnd fibula, when those nuiacles nnd the gast 
inius are t<i be tinned down, and the biir«a between the- tendon t 
tlie (IS calcis notic<'d. The posterior tibial vessels and nerve, jiortia 
covered by the deep Liyer of fascia, will now be exposed, and ben 
tliem the deep muscles of the leg, with tile poplileus cuvei'ed \>j i 
fiuiciA above.] 

The PopliteuB (Fig. 82, 9) is covered by a strong fiiscia which | 
mainly derivetl fi-om the tendon of the semi-raeuibraiioeus, and ap 
which rest the lower pails of the popliteal vesjieLs and nerve, 
must be removed to expfise the oblic^ue tibtes of the muscle, and 1 
incision must be made through the capstde of the knee unmedi* 
in fniut of the external lateral ligament if it be desired at thiit »tJ 
of the dissection to see its tendinous origin. The ixipliteu* < 
from within the general caiisule of the knee (though oulaide 
synovial cavity) by a round tendon, which is fixed to the anter 
extremity of the pojditeal groove on the outer side of the exte 
tuberosity, below and a little in front of the tubercle for the otti 
ment of the external lateral ligament. Tlie tendon pusses bene 
the long external lateral ligament, and is intimately connected will 
the short external lateral Ligament. It occupies the long poplitc 
groove only during flexion, but occasionally a short extension 
is found upon the border of the outer condyle. It grooves 
external semilimar cartilage and runs obliiiuely over the back 
the outer tuberosity of the tibia just above the superior tibio-fibt 
joint, sometimes establishing a communication between this artia 
lation and the knee-joint by means of the buisal extension of 
synovial mendirane of the knee which invests it. It is intrr 
nearly the whole of the triangular surface on the back of tha 
part of tlie tibia, above the oblitjue line. 

The ptipliteus is a flexor of the leg upon tlie thigh, and 
or rotates the tibia inwards during flexion. It is supposed aim to 
piuduce that slight lotation inwards of the tibia, which takes pli 
at the commencement of flexion of the knee. It is tnjtjiluil bjr-J 
blanch of the internal jMipliteal nerve, which winds round the lo* 
border to reach the anterior surface of the muscle. 

fTlio deep suWileal or intemiuscidar layer of fascia of the 
belu^; tvuioved, the (jostcrior tibial vessels and nerve are to l<e clean<| 
when the tubjucuit muscles will !« found in the following puait 



I. 



rLEXOB LONQUS DiatTOBCM 

-flexnr Ii<nj;u» >liKit<iruiii most inUrtiuUy, 'tiliinlia pontieiu iu tlic 
liiiiile, auil flexur Iuiikiih ImlluciK lu Ihu ouU-r Me.] 

Tbe Flexor XiongUB Dlgitorum (FiK- i)i> ij) !* ■* p«uni> 

muscle iiritimj from llic posU-rior 

rfocc of llif tibiu Ix-low tliK olilir)iii? 

nnil intcnially to tlie atUioliiiii'nt 

le tibinliit |M>iticii8 (fn>m wliirli it i» 

tinted by iin imIiHtiniTt verticAl niX^v 

n int«rmuEculiir Mptuiu), thu luwer 

I uf the luusclu reaching to witLiii 

inchts of the lower euil of the 

It elidit iti a single tejiilon, whicii 

t'8 to the outer ftiile of tliut of the 

IK poMicuK at the ankle, and i>n»Dt>ii 

gh a «-]>nrnti^ division of the iii- 

lunniilar li^Miiieiit : tlien iiijoii the 

ner Mirfuc^ of the iiu«t4.'nlui'iilum tali 

lie Bole of tho foot, where it will 

s«ett breaking ti]i uit<i four tendons, 

ich give origin to the Inmbrituileh 

111 ftfU^rw'onU {lerforatc tlic tondonx of 



. n,^-ATt»rlMOf (he baok nf liie I«tr (fhini 
BnoHiny and Bmu). 

|. Adiluctor uuirnus. 

' iiptiiiun. 

M('lliiu«. 

I . 

H ulnr aiUi). 
r iiii. iii.ii .11(11 iiliir «rl«ry, 
don of hiicin, 

"trns. 

I iirtery. 
iiim. 

LiDK luiiRch will) iHinmenl 
*ry. • 

il>illli« (KMticUlt. 

" . i*. 
iiimt. 

T tibial artery. (g 

^K AllK^I-jnx'llt "II Tin I'lU L of tllO Ot OHlcJA. 




174 



THE BACK OF THE LEO. 






the short dexor, to become inserted into the ungual pholan^ 
of the four outer toes. In the sole it will be found reinforced liy a 
fibruus slip from the tendon of the flexor lonj^s hallucis. 

The Tibialis Postioua (Fig. Si, 15) is the only one of the 
deep luu.scU-s whicli is attached to both bones of the leg. It ii 
covered by an aponeurosis which fornw s«pta Wtween it and the 
adjacent muscles. It (irij»;« from the posterior surface of the tibia, 
below the oblique line and externally to the flexor longu« di^'itorum, 
the origin extending to within two inched of the ankle ; from nearly 
the whole length of the interosseous membrane ; from the whole of 
the internal surface of the fd>ida immediately behind the intenxseiHU 
line, and from the intermuscular septa on each side. The Ahm 
end in a single broad tendon, which passes beneath that of the flexor 
digitorum at the ankle, and then to its inner side, nmuing in a gronve 
at the back of the intenial malleolus and in the most internal diviiiuu 
of the annular ligament to the sole, where, after passing over Ihu 
deltoid ligament (above the sustentaculum tali) it is atUiclud to the 
tuberosity of tliu scaphoid bone and give-i slips to all the other 
bones of the tarsus, except the astragalus, and to the three middle 
metatarsal bones. 

The Plexor Iiongus Hallucis (I''ig. m2, 20) is a well-markeil 
hipejuiifoiTu muscle, arisiuy from the posterior surface of the libuU 
below the origin of the soleus to within an inch of the ankle ; anil 
also from the intermuscular septa between it and the peronei muscle 
externally .iiul the tibialis posticus intenially, and from the lower juirt 
of the interosseous membrane. The muscle ends, at the level of the 
ankle-joint, in a tendon which lies on the back of the tibia to the 
outer side of the posterior tibial vessels and nerve, and, passinji! 
through a sejtamte division of the annular ligament, winds to the 
sole of the foot through a groove on the posterior surface of thftJ 
astragalus and beneath the sustentaculum tali to reach the ungimll 
phalanx of the gi-eat toe, where it is inserted. Its tendon givei M 
slip to tlint of the flexor longus digitorum in the sole. I 

The flexor longus hallucis and flexor digitonim are direct tlexotal 
of the t<^es and plantar flexors of the foot. The tibialis posticus i»M 
also a pliintiir flexor and an atlductor of the foot, the first movemeuti 
taking place «t the ankle-joint, the secoml at the articulation formvdl 
by the astri^ralus with the calc^neum and scaphoid (talo-culcaneu^ 
scaphoid joint), and helps the other tendons to maintain the longita-J 
dinal arch of the foot, giving powerful support to the keystone (hotdl 
|,of the astingahus). The flexor longu.s hallucis, by means of iu acces-l 
MOiy 8lip to the flexor digitonun, aids iu the flexion of the smaUerl 
mw. The three muscles are tuyplieil by the posterior tibial nerve. I 






-r » --_.t 



THE POSTEBIOU Tl UUL AMTKKY. 



175 



Surgery.— Tlie form uf iliiI>-root cnllcil 'tnlipc* vani»' which 

causes till' [lutinit to walk on the outnido or even ou the duiiiutii •>( 

tie fool. If. nA-ip<-ijit«il witli n (.'oiitriK'tion of thv lil>jal)>i [Mwticux urn" 

soimtimi-ii of the flexor liigiloram. The opi-mtion of iliviilinj; the» 

' " ' ■ ■ ■ ' niied iiuiiu-ilijitfly aViove tlie inU-riml miilk'oUw, a ' 

rioUimy knife Ihmuj; uwd :ilt<T tlic first iminioii, to 

r of wouuJiiif' ihf posterior lihiiil urtfry, Iml tlio 

■ ainl I'veii iho iMuira bo fur lukv [(url in ihu ilefor- 

-^- . :-;iotomy iilone priMliiwM little immediate result*. 

The Posterior Tibial Artery (Fig. 8jJ, n) i« the direct cnn- 
tiniiation of tin; jiopliteal (iiitry, iuhI begins nt the point of bifurcR- 
tion of tlmt ve-ssel, which is \i»ually thu lower botvler of the )>opbt<.<u« 
mu*cle. In the upi>er pnrt of ilo courne the puBlerjor tibiiil artery 
lies between the superficial and Jax:p muscles of thi; back of the leg, 
but bcloMT the origin o{ the soleiis it ia only l)ouud down by n ]>ro- 
longatiou of the intermuscular layer of fascia, and lies by the side 
of the tciido Achillis. It rests (in the {Kwition for dixsectiunj upon 
the tibialis jMiaticus for two-thiiils of its length, then upon thu 
flexor digiluruiu, and at the unklu upon the tibia between thu 
tendons of the flexor digitoruni und lluxor longus hulluciit. The 
resurl afterwards passes through a s|M;cial canid in the internal 
unuiilur ligament t<i the iuter\'»l Ix-twcen the inner malleoluii and 
the heel, wlierv it divides into internal ami external plantar arteries. 
The j)o»tiTiiir tibial nerve is in a dose ndatii'n to the artery 
throughout, lying hrtit to its inner siile and then crossing super- 
ficially to its outer side, in which relation it coutiuues to the foot. 
The artery hoi two ivnas comUa, which join those of the anterior 
tibial artcr)' to form the jHipliteul vein. 

Burjtery. — The o]>eniliou of tying the posterior tibial artery ia 

ildoni pel-formed except on the deud Issly, liut the ves-'el may l>e 

cheJ in three parts of its course. Behind the malleolus the 

ry is remlily cx])osed by a semilunar incision two inrhes long, 

Da<ie three riunrters of an inch l>ehind the margin of the bone, thu 

dge of the knife Ijcing diroctwl towania the tibia so as to divide the 

' inti-mol annular hgument. At the lower i«iit of the log the vessel 

may be n-iuhed by a vertical incision a little vn the inner side of the 

teado Achillis, aii<l will Is' found lying uj>on the flexor digitoruni. 

In (he middle of the leg the operation is one of some dilliculty, and 

fhftt damage.^ the dissection if performed. The best mrnle of 

ding is to make a verticid incision four inches long, parallel to, 

slf an inch behind, the eilge of ihe tibia; the g'.utttornemius 

ip« nsiile and the soleiis is then to be diviiled. esj>ecial care ln-ing 

.ken to cut Ihmiigh the tendinous ex)>an.-ion on its anterior surface 

jt to go no deei>er. A little di».»ection, close l)eiieatli this tibial 

Itachiueut and towaixls the fibula, will expose the intermuscular 



,^5^ 




THE BACK OF THE LEO. 

foHcia and betioitb it the poeterior tibial artery lying apon the tibiolii 
posticus, with the pufterior tibial nerve to its outer side. 

The Branches (Figs. 82, 83) of 
the iKwti'riiir tibial artery ore (1) 
jwnniftil ; (2) niu«.'ular ; (3) tat- 
duUarj' to tile tibia ; (4) coniiuu- 
uiuitlii^' ; niid (S)inteninl calcauun. 

1. The Prrmital (Fig. 82, 18), 
always of coiixick-rable size and 
soiaL'timeg loi-ger than the poxtei 
tibial, comes o(f about two ini 
below the popliteus. It lies at 
between the tibialis posticus and 
solcus, b\it afterwards passes 
the fibres nf the flexor Imllucis oud 
runs close to the iuner boi-der of the 
fibula aliuusi as for as the lower end 
(if that Ixiue. In this part of its 
course it ^;ive» miuaiUir branchea, 
and the /»f(/«/if(ri/iirtery totbelibuU. 
wliich hns a downward direction ; 
i.e., runs from the knee-joint. It 
tlien gives a goo<l-sizcd 





Fig. 83. — .Vnutomote* of tibial 1 

1. Anterior tibial reoummt. 

2. I'oplitfiil. 

3. PoBtirior tibial, giving oft' ; 

mid iiieduUiiry braiichi-s. 

4. Anterior til>iat, giving uff |inatniar 

tibial n-i'Um'Ut anil «u{wriur flbaW 
bi-fori: {licrring iiitoroancous rot) 
braiioniid ooti^rior tibial 1 ~ 
3. Tibia. 

6. Fibula. 

7. Anastomoain iif iiitenml lUiilKitlor < 

anterior tibial with [Htitmur i&t4 

nitl irinlleolar. 
6. PtTonml. 
9. Internal colranpan. 

10. .Vnit'riur fwronenl. 

11. lutonifll nnd extrnuil plantar. 

12. IV'ittt'rior peroneal. 
14. Coiiiiiiunicating. 
16. Exti'mal malloulor of ■otcrior ' 

joining iKMUrior pcraoeaL 
18. Astnundus. 
20. Exteninl calcancan. 
22. Calcanrum. 



iuSTE|lIOn TIBIAL NKUM., 



177 



lich, through the intproswoiw luc-nibnuie, to the Tront of 

Lk;g, where it will nft-Twuiili Iw ili*M.'ct«l ; nml in joiMe<l by a 

H' • 'fith fioiii thi- iKjHtoriur tibiuL iLs tvrtuiiial brtiuch 

J /(Mil, which jiitssfa overthi* jxMtrrior iiif'-riur tibio- 

9ar ligaiucia to auiutouumi! with the iiuillrohir artt^rim uuil 9iii>])ly 

outvr side uf ihi- rulcanfuiu, thciu joining with the calciuuun 

lichca uf the iio»t<Ti<ir tibial fttiil with the citcmiU |>liintar. 

Muteular bnuichi-i arc giv<>u to thu deep uiuacK'x and oIm ta 
laoleoB. The hiKhixit of thv«e tuay send A twig to join tho UMA- 

•iii aliout the kiicf. 
'A. Tht; JtMuUurif tMety Us the tibia is of Urge huu;, voA enten 
the forainun on the posterior nurfoco of that honr ; it arisen from 
the upficr part of the [ulterior tibial, and has a direction from tho 
^Be-joint. 

^B. A I'tnniiiittiic/itiiui (17) branch riinii traiiDversi'ly imnietli«toIy 
«V»7e thu Mnklu to join the puruueal ariury or itit itontenor tvnuinal 
^mi><°h. 

^HL a I'o'tervT Intrniiil MttlUnlnr i>i umiidly found a little above 
IHtualleuhiit, runninj{ tnuifivenwiy beneath the tcndoiu of the tlexor 
(Ii^itonitn and tibialis jKinticiu In rcor.h the front of the leg, and 
*tonio«o with the internal luollrolar of the anterior tibial. 

The Intrrnal iMctmnin (23) in « branch of viiriublo «i/.c, tvnd 
be replaced by two or uiore (iepunitt> arterie*. It ari»e« from 
[ jMjttertor tibial lieuunth the internal annular ligament, piercing 
) Utter to »>U])]ily the inner vide of Uie u» i:akis, with the adjacent 
I and the iuteguuiejit, and to anontoniOM: with the cidcuiieaii 
aches of the i^cruiiuul und external iilanUir. 'Phe!<e calcuueun 
i-U nourii^h the heel Hup after 8ynie.s' anipiiUition ut the ankle, 
must hence be dcjilt with K'>-'"tl,V '" 'Wh njivrntion. 
lie Anterior Tibial Artery (Fi^- >^3, 4) is seen jit/tt before 
the intcro«8eouj) membran-- to teach the front of the le>,'. 
I otf two braucheM while in this position : tlie jmttrru/r tibial 
r&eurrtnl, which runii upwanl over the bead uf t)ie tibula, to otuu- 
1 with tlie inferior external articular ; and the ruprrior Jihular, 
wiml;< around the neck of the fibula to aniutomcMC with the 
lor tibial recurrent. 

Posterior Tibial Nerve (Fig. 84, 19) is the continuatioii 

inteniol popliteal trunk, anil piuMes with the artery beneatli 

It, to lie on the deep mU6cle>< of the bock uf the leg. It i^i 

\tt fint to the inner side uf the posterior tibial artery, l>ut 

etrrasei that veatel in the upper part, and lies tu its outer »iile at the 

■ lid in the same division of the anuiilur li;^aiuent. The nerve 

uuiir the joint into intenuil and external [dautar broiichca, 

II. N 




178 



THE BACK OF THE LEO. 



and if the divisiun takes place above t)ie inner uiolleoluii, tlie 

are uaually found on either side of the artery. 

The jiosterior tibial ner*-e giv 
Fig. 84. wiiMMlar brantbes to the tibialis ] 

ticus, ticxar longus digitoruiu, fles 
loBij^us liallucis, and Koleu.s, and 
liriinclies to the vessels, bones, 
iiiUTfiswoufl Tiieinbrane ; finallv, 
the iiukle, it aem\» olf n cut 
riilfamo-plantar nerve (20\ wli 
)iiertes the internal auuulnr lignme 
ma! fiiseiii at (be inner rtide uf 
ti iiilo .\eliilbi*, imd niiiy t>e traced 
till' -kin of ihc bee! ami sole. 

Parts behind and belo'w 
Inner Malleolus (Fig. fiS). Allbou 
ibe M'Veiid jiart:! liehind the int« 
iiuilkulus are only continuations 
tbuse which have been olreatly 
f<ected, especial notice should be 




Kig. M. — Deep dimwtion of the Iwirk of 1 
Irg (from HiriM hfeld and Ix'vcillc). 

1 . ro|dilt'n1 nrttTv. 
'^. Ureal sciatic nerve. 

3. Adduetor uiu^iu. 

4. lliceps. 

6. Siijwrinr Inlcmnl nrticulor arten. 
(i. Kxti'rtoal pojdiK'il nerve. 
7- Ciiistiorticniius (I'Ut). 

5. Aiitfrii)r tiliinl nrti-ry. 

i). Tendon o( (cmi-nipmliranoiqu. 

lU. I'rroneus ioumm. 

11. Sural urt^'ries nnd nerve». 

12. rcronent nrterj. 

13. Intpmul popliteal nerve. 

14. Tibifilia pnnticug. 
16. Portion of soIcuh. 
16. PcriineuB brcrin, 
1". I'opliteu*. 

18. Flexor lonsnis ballurig. 

19. Fosterior tibiiil nerve. 

20. Cnlciuii'iin timnch of posterior libinl nWj 

21. J'o«Lerior tibiul urterv. 

22. Tendo Achillin. 

23. Flexor longua digritoruni. 
26. Tendon of libinlia po«tiru9. 
37. I'lantar nerrcs. 
29. I'lantu- lU-trriM. 



THE SOLE OK THE FOOT, 



179 



iif thein in this jxirt of their course, as thi-ir relations are 
important. 

A jiorfion of the skin on the inner side of the heel ami sole ia to , 
W reflfoied if necessary, so im to expose the whole bruacUh of the I 
inUrtuil iinnular liyaMcnt, which 



Fig. 8.5. 




ia ■ thickened iMjrtion of the deep 
hfcia of the leg stretching from 
the inner malleolus to the o» 
cftlcis, and giving origin liy it* 
loin'r border to the iilxluttor 
hjJIucis. 

The divisions in the annular 
liguiirnt are four in nuniWr, 
and are occupied lut followK, at 
the level of the ankle. In the 
first and innennost division is the 
tiViialis p«i»lii;iis ; in the second 
i'lon of the Hexor lungus 

iim ; in the third the jioHterior tibial vessels and nerve ; and 

II) the fourth and most cxtenial the tendon of the flexor longius 

hallucis (Fig. S6). B-.-low tbt- Inllll^•ul^l^^ (Fig. Hb), the tibiulis 

prsticus tendon is highest, and crovxes tlie intcnial Ititeriil ligament of 

the ankle above the i^ustentaculiiiti t-idi tu reach llie tiil>en.'le of the 

fcaphoid ; the flexor longiis digitoriini, next in order, runs over the 

outer tiuface of the sustcntjiculuni tali (but nirely grtjoves it) before 

diuppeiuing benenlh the s<jle ; litsfly, the Hexor longna hallucis 

tnxtt in a groove behind the astragalus and lieneoth the siuttenta- 

vAxm tali. Tlie onler then of these three tendoiit^ t.s here the siinie 

fcom alxive downwunis as it wai* from within outwaitls at the back 

"I lbs ankle. The plantar ves-sels and nerves are superliciul to the 

llunr longii? hallucis tendon a* they approach the sole. Each of 

tie teoilons is lubricated by a distinct synovial membrane. 



,1.- 



Thb Sole or the Foot. 
[Ilie foot being mised on a block so that the sole may be fully 

Fig, 86. — Relation of pirtt brhind nad below the iiuier midleolua (from 
Hirnhfcld imd LcTpilk'). 

'.1. 7- ■• !ica». 

It. 



4, 4. Flexor Inn^ia digitorum. 
6. Posterior tibial arterv. 
8, I'Mteriiir lihiftl nrrvt. 




,.?'>« landoo of the flexor longiu haUncis u too deeply pki^d to 1>e ihawn ia 
""» ri«w. 

n 4 



I 



180 



THE SOLE OF THE ROOT. 



ex|«iHei1, an incision ii> to Ite madv down iu centrt.' ' ' 

thi- liftscs of the lot'js, the knife In-inj; earritxi at I'l 
glistening pluntjir taiwia throu;i;)i the thick lobiilulir^i : 
ttlwnyit fotinil hi-iienth thc< nkin in this rej^non. A ininss i 
at tlie r<Ki|« iif the t<X!» will alhiw the skin an«l fat to iit- 
each niili', if the knife in kept l-Iow to the fnacia and pn 
fihrcB. Near the toes cure must be taken of tlie divi-. 
plantar fascia an<l of the digital nerve* which npjxfur 1« i 
eB)>ecinlly of those to the inner ifidc of the Hi-st and the ■ 
the flflh toes, which pierie the fuwia furtln'r Imck tliuii '■ 
liiit no attempt need be made, except by the ndvaDccd . 
tnice otit the minute cutaneous bruncn from the post4'riot • 
near th» heel or the Rtill sniallor twigs of the intennil ]il.> .^ 
diHtributed to the sole.] 

In the dtatcriptiun the t«rnifi pnperficial, deep, &c., neceasorily hIh 
to the position of the parts ns trtn in 
the diiwection, and not to tliat whirh 
they would hold if the boily wew m 
the upri);ht position. 

The Plantar Fascia (Fig. »7, Ji 
doBely ix"<emblea the foBcia of iht jnCii, 
and i« divisible into three portii.i.-. 
The ceutrnl, wliich isi the stroii;;—; 
is attached to the under iiurfa<-' <>f 
the gi-eat tulnrosity of the •;■* cal.i-. 
but, a« it pu^Des forwarrls, expun<ii Ui 
nearly the entire wMth of Uie (ml 
It Rplits into five portion.^ opjxtiitc 
the heads of the nietatar»jil tH)nei>, ami 
at this ])oint distinct tran^verMi fil)N» 
will be seen passing acroM the foot, 
beneath tlie lon^tiidinal fibres. The 
iive proceHses ai-e uttachucl to the si<le8 of the proximal phalanx, uod 
to the sheath of the llexor tendons of each toe, and l>etweeu tliem 
pass the several diffital vessels and nerve*. 

A ni-perficial trainverse Ivjniiinit, like the fascia of Oerdy in the 




Fig. 86.— Section of the rif bt uklo (dmwn by Q. E. L 

1. ExtoDtur lotigus digiloruin uu<l 

peroneua tertiut. 
'2. I'ei'oiu'uit lon);uB. 
8. Kxt£iikor iimpritu pollicit. 
4. l'er«neu» orevw. 
i. Anterior tiliiiil vcuk'U and nerrea. 
6. Flvxur lonjfUM baltucitf. 



Peuw). 



7. Tibiulu unlii'us. 

8. Tendo AchiUiB. 
0. Tihinlia poitirui. 

10. Vlantnri.s. 

11. Flc.iur loiigus diritornm. 

12. Potterior tibiiU reMclaJ 
nenren. 




Tm; PI.ANTAR TASCIA 

n in tliP nkin of the web of t 
\\» ami niTves, ami Ixwuniog coutinu 
of the bXB antl ilurBum of 

central portion of the 

^vvB tjrigiu U> niawalar 

by it* durp «iirfac«, uxl 
ty two iuterinuiiuiilar w^ptn, 
I will aiiWiiiientiy 1i<> i>t'(>ii 
idi »iUn of tl)«< fli'xor lirvvix 
IHiMi. The liitftiil (MirtioiiK 

) jilanlur fu-xciu uiv nitieli 

r lluui that in the cvntre, 

Doinly nivcr the intiMlex 

gn«t ami litttu tnca nn 

ntT ninl outer nidm. of 
Kkt, bnt th^rc i« u atning 
oti the iiiitfr hIiU' riniiiiii|{ 
the ouU<r tulieifle of the 
learn to the lNb<u of the 
l&eUtUiniiil bone. 

le c«nli-.i1 portion of tlir 
i> to Ik' cut lU'roMaliont two 
1 fnim tlie lied, ami nmv 
be lumi'il down over ihe 

tliiiiit injtti'inc (lie diuilal 

, when th<- tiexiir ln-evin 
^uni will Ih' i'X]H»cd iu 
nod the int(■^nlu^culur 



182 



THK SOLE OF THE FOOT. 



The Pirst liayer of Uuaoles consigto of the flexor Urevit i 
torum in iLe middle, the abductor hullucis to the inner side, osii 

the abductor minirai digiti b> 



Fig. 88. 




tho outer side. 

The Flexor BrevlB Sigi- 
torum (Fig. S8, i i) aritei Jinni 
the anterior bonier of th> 
tuberosity of the ••* ■ 
from the plantar fa- 
it (u'liich hiu the I' 
left umlisturljeil; ; mid tnuu 
the iutenuuscular septa on each 
■lidi'. It divide-i into four 1 
dons, which ]>as3 into tenJin 
Hheatha on the under »u 
of thi: four anuvller to«8, 
are perforated by the l«ndoi 
of the lung lle\or us in 
liand (7. r. ) ; iind are in* 
rach by two slii>s, into the»iil 
of the second ]>halange8. 
tendon to the little toe i» 1 
a mere thread. 

The sheaths of the tinidiJ 
resemble those of the hu 
but are smaller. Begin 
over the heads of the 
tarsal bones, each sheath ' 
joined by a process of planQ 
fa.-(cia, and then extends to I 
l>ase of the temiiniil jthn 
The sheath is .*trong opp 



Fig. 88.— Superficial diaiecti0ii of the sole of 

1. Greater tuberotity of os calcui, II. 

2. Lenarr tuberotity of o« calcts. I'J. 

3. Cttluiiii'iiu bruucli of ]H>iiterior 

tibial urtcn'. 13. 

4. Abductor minimi digiti. 14. 
0. Pl.'intor fuwiu. Ifi. 

6. External plantar urterj'. Ifi. 

7. Altductor niUluci*. 17. 

8. Flexor breri* rninimi digili. 

0, lulernul plantar artery. IH. 
10. Atth between plnntar arteriea (not 19. 
L'onitant). 



the foot (from Bonamy oud i 

Flexor brevui difritorum. 
Third tendon of ttexor 

ilif^itfiiun). 
Flexor longus lialluri*. 
Lunibricnlis of 3rd apuce. 
Flexor brevi* hulluci«. 
Ilifrital uriery of 3rd space. 
JJilfilnl bntnch from doml 1 

of foot. 
SheulU of tendons. 
Digital artery of Itt •paee (ft 

dor>uil nrtiMj- of foot). 




THE PLANTAR AUTEUIE8. 



188 



«!iafl nf each )>)iiili(ux ' '.i tiufiniUf), Imt thinnrr nvnr 

JuinUi, M) OM not tu iiiii' ' luutiun ; iiml, when iliviilmi, 

will htt fouiiit III be lined liy a nynoviiil nieiiibruiie whiih t» rvtlvctml 
e? ih: t4.-uilona. Small ebutic boncU (rincuta latculota) cuunuct 
tvtuluii i}f the flex(ir lirevix with the front of the hrat plialiuix, 
the hand. 
The Abductor Halluoia (Fig. 8«, 7) aruui from the internal 
^uliir li^'uinciit, fivin lin' iiiniT tuberoHity on thu under unrface of 
foe I'jiliis (iiit«rn/d in Ibr nrigin of the lli-xor bn-vi>* digilorum). 
tlif ]>littitnr I'liwiu, frmn ihi- intt-niiusvulur wjitnni Vn-twiwn it 
i the tluxur litrv t.t digiloniin, uiul from tht; (luic'm on ihu iiiuvr iiidu 
'^Ihe foot. The iiiuiwli! rmU in a Imwd tendon, which in joined by 
Uke inner hoiul of the ili-xi>r brevi.t hallucix, and is iiiitertM into the 
er side of the ba<H' of tin- firxt |>liidaiix of th<? groat toe, ond by a 
Du« rxjmnsioii into the iiiiipr mde of tho lonj; uxteiiKor tendon of 
I hanir toi*. 

lie Abductor Ulnlmi Dlglti (Kig. 88, 4) ariie4 from llic 
' and inner (uU-tHisilie» of ihi; on culci* in front of iho llexor 
digiluruin ; fnjin the plantar fiiscin and intRrniii:«cnlar 
■cptuiu ; and from the fiiscia of tlie ontiT Inir^ler of the fiMit a* for 
forw'itnl a» the base of tin- (Iflii nietntjin*4l Inme. It* tendon ix 
, iatffitd iiiti> the i.uU'r side of till- ba»»! iif the Br»t phalanx of the 
tot.* 
lie actions of the miperlictal miwcleH of the foot are partly 
uted by their imine«, but it should Im' retiiurked thnl alxlui'.tion 
', adduction art; from and to the iiialiiin plane of the foot and not 
be UkIv. The ttUlucUirs are aI.-«> flexors of the toes with wliich 
arc connectisi, and the whole of the plantar mu:<clc<4 aid iu 
Staining the lon^tudiuid arch of the foot, 
lie flexor brevis dijj^iturum und abduetor hallucii) are tujrplied by 
atvnml plantar nerve ; the aWuctor iniuimi digiti by the exlumal 
litar nerve. 

fo brina the ileejier part* into view, the beat way will lie to 
Ruve with the 8aw n thin slice of the 116 caleis, including the 

c)unent« of the .^UfH-rliiial inu»cle^ when, if the attnchnient of 
[abductor Imlluciii to the internal annular ligament Im: divide<l, 

' can be turned forwurdK, luid the ])knlar iierveB und veasebi will 




b<? Plantar Arteries (Fig. 89), internal and external, are tho 

W'ihhI ha* ilr^Ti-iU'il on abductor intit nwttitatti ifumti, wliirti in 
oil lieueiilh the uUluct/ir and attaiUiil to the l>uK of tliu Uflb 



184 



THE SOLE OF THE FOOT. 



teniiinal branches of the poaterior tibial, and enter the foot benettli 
the alxluctor ballucis and in close relation with the plantar norrek 

TliB internal plantar orteiy, 



Fig. 89. 




which i.s the smaller of llic t» 
is acounipiinied by the large 
temal pluntm- nerve, the l»i^ 
extenml plnntar artery giving] 
with the smaller e.\temal nerve 
Both vessels are accompanied 
veiiie eomitca. 

The litlenial plantar 
(7) is usually of small eize, aulj 
runs forwiird in tlie fascial 
tniii l)etween the alHluotor iii 
luoi.- and flexor brevis di^itoruntt 
til the great toe, where it aua»>J 
ti>ni08e8 with the internal an 
ciininiunicating branches of tbt 
dorsal artery of the fi«il. 
well-injectcil it may Mnuetin 
l)e traced with tlie wer\-e to ' 
thiixl interosseous space, joiniq 
the digital branches to the thr 
inner toes. 

Tlie External plantur 
(4) nina obliquely outwa 
across the foot between 
flexor brevis di^itoruni and tht 
uccessorius mutsrle, and, tumio 
round the oviter border of 
latter, coiirses inwards beneath 
the digital tendons towaithi the 



Tig, 89. — Deep diuection of the >ele of the foot (from Bonamy and Beau). 



1 . Oi calcui. 

2. Liguiientuni longuni plantir. 

3. Poitcrior tibiiil artery. 
i. External pbintar artery. 

IIKU 

6. Tendon of peroneus longua. 

7. luterual pliinUir artery. 

8. Baw ofSth metut«rsaf bane. 

9. Tendon of tibialis poiticui. 
10. Plantar arch. 



UallJ^ 



lal p 
10ft 



S. Tendon of Hexor longuit linlliicU. 



11. Prolongation of tendon of til 

poatteu«. 

12. Digital artery. 

13. Communicating branch nf donal 

artery of fftot. , 

It. Plantar interoueou:* of 2nd apace, 
\5. Donuil intcroa«enu8 of 2nil apace. 
Iti. Tendon of flexor longiu aijpl 

rum. 
17. Tendon of Sexor longtis hallucu. 




THE PLANTAK NKRVES. 



185 



it will !><• dulisi-quenlly tnitwl, juinin); tln> coni- 
h of the cloreul uitcr.v uf llie fuot uiiil uitiijileting 
Mvh. It i» nco.<'im]>auit;iI by the vxIviiihI ]<Uiitttr 
I give* a dcofi limnch acniM tlte fuol) uud nuppliM 
tcl«*, Kiviiij,' a 
tvr tiiiv of the 
with the cx- 
of Ihr 




r 



Varvet iKik 

f/xU'nial, all 

the iRi«ti'rim- 

M tvlutioti U> 

<?vn mcntioiicc]. 

[antar nare (5; 

tlie two, and 

biall iMitAiiiMiiii) 

I und tuUMular 

r aUluctiir liul- 

ftvi* diKiti'i'uiii. 

tal limiicli U> 

tlui great loo, 

»Ui thh-c <ithi-r 

wliidi lie Ih- 

' foM-in and tlir 

ixor bivvin digi- 

llOM.- birtiKttteo 

t hiet aiid tlii-y 

lt«r tide of tln- 

tiilt'K tif till- 

tiM-K, and tbi- 

riuirth toe. Tbi' 

ih aIihi nui>|>lioit 

Wluci*, the 



Ttt«HiHi mlc of till' foot (fWim Uindifeld and UvcllU). 




Ulpunvnt. 
^tnnini (<ut). 
' nervv. 

idl«ili. 

vtvn. 



10. Fl. ■ 

11. 1-|. 

12. Fl.- 

13. Digital bittjiclics 

[iluiitiir norve. 

14. Digitiil liniiirliM of 

(ilunlur nmn'. 
16, Flvxiir lirurin liitUuci*. 
10. One nf thr lunibrioalr*. 



.lilfiii, 
of intern*! 



mtonwt 



186 



THK SOLE OF THE FOOT 



sccoml and thinl supply tlie Hret ami secomi liinibricolw r u peB- 
lively, iiTnl the fmirih i« joinwl by a twij; frum the extenul 
plaiitJir iierve. 

The Extrriint plantar iirrix (3) crosses the foot with ftinl in fn 
of till; external pliuititr iirtery, giving liraiiches to the abducti 
iiiiniuii (ligiti aud occvKsorius in its course. At the outer boitleri 
the aceejisoi-ius it divides into superficial mid deep jwirtiona; 
deep aecompanics the artery, und will be seen in n later dis<ertifl 
Tlie superficial portion gives cutuneoiis bninclies ti^ the outer ]4 
of the sole, and divides into two digital branche*, one to the out] 
side of the little toe, — and from this commonly are derived branch 
to tile flexor brevis inininii digiti and the interossei f>f the four! 
npuce ; the other, bifurcating to supply the inner side of the litl 
and half the next toe and the two outer liinibricales. 

A slender branch of coniniunication Wtween the inteniaJ 
extenial plantar nerves may soinctiines lie found. 

It may be noticed that the nerves of the sole of the foot clo 
resemble those of tlie palm of the hand in their distribution, I 
internal plantar con-esponding to the median, and the extec 
]>lantar to the ulnar nerve ; the deej) braiichea of the latter lie 
also correspuml. 

The Second Layer of Muscles includes the tendons of 
llexor longus digitoriim and flexor longiis liallucis, with the acci 
sorius and the lunibricales, idl of which should now be cleaned. ' 

The tendon of the Plexor Ijongus Dlgitorum (t'ig. 90, l^ 
nins uptm the inner surl'iuc of the sustentaculum tali to the inn 
side of the vessels and nerves, and crosses l)encath these and suix 
ftcial t<i the tendon of the flexor longiis hallucis to reach the cenfl 
of the foot, where the fibres of the accessorius are attached tfi 
deep surface ; a siuall slip from the Qexor longus hallucis tend 
joining it at a somewhiit higher level. It then divide* into fo 
tendons, which give origin to the lumbricales muscles and 
beneath the digit^il nerves to the four small toes, whei-e they euS 
the digital Bhentlis, lying beneath the tendons of the short llexa 
Each <lee[i tendon then passes thi'ough the slit in the »uperficii 
tendon as in the liand, and is interted into the biise of the third 1 
termiiiid phalanx. 

The Accessorius (Fig. 90, 8) aru»j> from the under surface 
the OS colcis by two heads, lietweeii which is seen tlie long plant) 
ligament. The inner head, which is fleshy and the larger of iho 
two, is attached to the concave line separating the inferior from I 
^tenial surface of the calcuneiim, ajid to the inner edge of the Ic 
utjir ligament ; the outer head, which is tendinous, is attach 



THE FLEXtdl I.ONOl'S HAl<LUCIS. 



187 



to tilt' Ixin*? in front of tin- lesser tiiljcruaily luitl to the long pLuitttt 
ligament. The niiisr.k- i« intrrlrd into tiic ducp siirfacv uiul outer 
iKinlcr of tbi* flexor longiii ili^ntonmi, ami xoncls slips to the tunilons 
comiect«l with the necnnd, tliiiil, and fourth tow. 

The Iiumbrloales (Fig. HO, i6) are four umall lunoclcs, which 
ore •<> named fr<>Hi their fancied ri'm-jiiblnnce tn earth-woniiH. They 
aritu from the letulun!< of the flexor longiw di^itonim, the n)o«t 

d from one, iintl the resit from two tendoiu cnoh, and wind to 

ii«r tides of the IViur «iii(il! U>v^ to rcueh their dorsul aHpocta, 
uliuie they ari- innrrtrd into tlu' comwjionding side* of the l>a.se« of 
the pmxiinnl iihaianges, Hejdoni joinini.; tlie exteiuor tendon« lu in 
the hand. 

The itttiim of the ttoecisorius is essentially to nuppleuieut the 
long flexor ancl to flex the toes when the flexor lon(;iu in tvhiied by 
the elevation of the hi-el in planter flexion. lli tendency to 
bring the line of traction of the flexor tendon* into the centre of 
the foot is pi'olwiMy of vprj' trifling wrvice. The degenemte 
ltuubricalc« of the foot are U-hs iuqiortant tlmn tboxn in the hand, 
•nd their fiuti'tion in umially limilMi to flight flexion and tibial 
addnotiun of the proximal plialaii'-ea. The utTenaoriviB ami the two 
outer luniliricaleK are nijipliril by the c.xtenial plantar Uerve ; ailil 
the two inner lumbrieolet by the internal plantar. 

The tendon of the Flexor liOngus Halluola (Fig. 90, i:), 
after lying in the groove Whind the iLstmgaliis and Ixdow the 
nislontaeuluni tali of the ns culiin, runs forward to the great to*-, 
ttsder cover of the planter vexnelii and neive», ami i>i cmmuhI )>ii|i<»r- 
fidally by the tendon of tlie flexor iligitortim, to which it given a 
•lip nf rvtliforcement. It then lies lietween the two headx of th«i 
flexor brvvi* LalluciH, and the two neiiunioid bonun with their con- 
"- ■ ni; ligament form u deep channel for it ; finally it runs in the 
1 formed by the ligiimentiim vaginale until itD iuitrtion into 
tlic Nu»c of the trrmimd phalanx of the great toe. 

The action of the muKcIo ih to fiox the great toe, to assist in the 
pluitar flexion of the ankle, and to maintain tlie longitudinal arch 
of the foot 

[Tbf long tendoni) and the uccetworius muscle are to be cut 
klmiit thi< middle of the foot iind turned down, when the muitcles 
of the third Uyer arc to Im cleaned. In doing this* the external 
plsntar vesseU anil nerve will be more fully, but not yot completely, 



Third Layer of Muscles conMsts of the ttt 



188 



THE SOLE OF THE KOOT. 



lucis, adductor hallucis, flexor brevis minimi digiti, Hnd tmiMT 
pedis. 

The Flexor Brevis Halluois (Fig. 91, 7) arua by a : 
tcndinuiis origin fi-oui the inner side of the tuboid, the In 
cakiiuco-cuboid ligiuuuit, mid from the prolongation of the tetitla 

of the tibialis poitioiiM to 



Ki?. 91. 




external and middle rtineifol 
bones. lt« fibres fomi two bea 
which diverge from each oli 
iieiir the head of thu uietatj 
bone, to be iiiierted into opp 
^ide» of the base of the tid 
phuliinx of the great toe 
the aMuctor und iuldiictor« 
s]R!ctively, and by mcane 
Hbrou:^ expansions derived 
I>art from the abductor and 1 
ductors into the »ide8 of 
extensor lougus Imllucis. 
head Liu< developed in itd ten 
n hti'ge Be'Sunioid bone, wh 
enters into tlie forniution of 
metatorso-phalangeal joint, 
tendon of the long tlexor 
between the two heads of tU 
muscle. The sesamoid 1x)n«« I 
the tendon form the ante 
resting jioint or pier of the" 
inner ude of the iduutor arch. 
T)ie Adductor Obliquv 
Hallucis (Fig. !)1, 11 ) arit 
from the bases of the «econ 
third, mid fourth metntiu 
Itoues, niiil from the long plonti 
ligament where it bridges ov 



Vig. 91. — Deep muscle* of the 

1. Shpiitli of Bexor luuf^iu hnllucii. 

2. 08 call-is. 

8, Sbealh of dexorlongusdig^tlorum. 
4. Li{r">niMituin lun);iiiii ^ilitntu-. 
6. Sheulb uC libiiUis poslicUA. 

6. Tendon of pcToni'Us lotigniti, 

7. Flexor liivvis hallui^is. 

8. Flexor brerU minimi digiti. 



sole of the foot (from Sappey^. 

il. Tendon of abductor hnlhiois, 
Mi. Adductor tnm8rer!>us hulluijj. 
II. Adductor obliquus Imllui-ia. 
Tendon of llexor bre> U digita 

to 4th toe. 

Tendon of llexur longus hallu 

Tendon of tlexor longiu digit< 

to 4th toe. 



VI. 



13. 
14. 



THE EXTEBNAL PLANTAR ARTERY. 



189 



"K peruneus longas tendon. It is iitttrUd into the outer side of 
lie bate of the first ]>hn1anx of the gn-at toe, with the miter hea<l of 
tif flexor brevift, and suods a dorxal slip to the tendon of the exteu- 
W loD^tis hullncui. 

Tiie Adductor Tranrveraus Hallucis (Tninsveresiis pedifl) 
(Fig. 5)1, loj i« of variahle si/e, iind consiBls of three or four small 
bundles, which arise from the plantar transverse inetatar«il lij^anieut 
OYtr the heailfl of the three or four nietntarsul hones, and scpunile 
Ihe ttniloiis and nerves from the interossei and vessels. It Uiiux-rteil 
into the outer Hide of the fir»t jihalaiix of the great toe, with the 
adductor ublic|uuj) and part of the Hexor lirevia halliici:^. 

Ativan*. — The flexor brevis, abductor, and adihictore.-< hallucis act 
h^gether in flexing tlie proximal phalanx of the great tue, and Ijy 
means of the dor^il gli]>s aid in extending the ungual ])hatanx ; 
the adductors draw the toe towards tlie middle line i>( the fuut, 
the abductor in the opposite direction. All help l<> inuiiitain the 
plantar arch. The flexor brevis hallucis ia supjilial by the internal 
plantar ncr%"c, the other muHcles by the external plantar nerve. 

The Flexor Brevia Minimi Digiti (Fig. 91,8) nrUeg from the 
nnder surface of the projecting base of the fifth inctatarstil bone and 
horn the sheath of the peroneuA longus, and is iitterted into the 
outer side of the base of the first phalanx of the little toe with the 
tbductor.* 

fThe adductor and flexor brevis hallucis are to lie cut near their 
urig^ns and tunie<l down, after which the jdantar arch of the external 
pluitar artery, with the aicom|mnying nerve, is to be fully tnned nut, 
and the lower aspect of the interossei taay lie detined.] 

The £xtflmal Plantar Artery (Fig. KU, 4) after turning 
around the uc^-easorius rnuar.'le Uikes a deep course iKMieath the 
(Uxor tendon-! of the lesser tf>e.i anrl the addactor iil>lii|Uiui and 
flexor brevis poUicis, and ."uperliiriul tu the interosseous niusi'les, to 
the btv*e of the metatarsal bone of the great toe. This deep portinn 
of ihe artery has been called the plunlar arch, anil is jointd by the 
rvmmuHirtUiiuj branch of the dor.-.alis pedis artery which enters the 
wle lietween the first and second metatarsal bones. 

Branches. — Small re-currtnl twigs pass backward from the 
concavity of the arch to supply the tarsus. Three amall ponterior 
frr/irrntinf) arlerie*, given ofl" by the plantar arch, pierce the 
intervals behind the origins of the 2nd, :ird and 4 th dorsal inter- 

• Ajifsor Ofit mrtiienrpi utiHimi Higiti attached to tlie mutatami bone may 
onanonslly b« foiuiil. 



190 



THE SOLE OF THE FOOT. 



osseous muscles and aiiiuitoiiii >«« witli the interusseon* urteriei i 
l)ie dorsum of tlie fool. Four diijilut nrlrrifs arise from the ant»fi 
part of the axvh ; the outer one guce to the outer side of the htl 

toe, the others bifurcate to eiipji 



Fip, 112. 



the adjacent sides of four ion 
toe«, and, at the point of bifi^ 
cation, send anterior perfiwatk 
arteries to the back of the fc* 
The dij^tal ai-teries run on I 
»ide8 of the toes with the digifl 
ner\'ex, and auastomo«e iu 
]>ul|>ot' the terminal pba 

The rommiiniailinij 
tht dormdU jttdii artery ftjj 
enters the sole between 
heiuls of the first dorsal iiitiS 
i>88eous muscle, and beside.s con 
])letiug the plantar arch, giv 
otf an inner brunch, which i 
beneath the long Nexor teni^ 
to supplv the inner side of 
t,'reat toe, and an outer bnui^ 
which bifurcates to sujiply 
adjacent sides of the great 
next toe, all anastomosing withl 
corresponding dorsal bnuuhes ( 
the dorsidis J>edi^. 

Tlie External Plant 
Nerve (Fig. il2, 5).— The do 
portiuu of the uerve accoo 
panics the artery tx>neath 
adductor obliijuus hallucis, 
which it ends. It gives 
branches to the adductor tmn^ 



Fig. 92.— P«>p dissection of the sole of the foot (from Hirsrhfeld and Lercill 



1. Intcrnnl plnntiir uerve. 

2. Abdiu-tor minimi digiti. 

3. Aliduetor hulluciit, 

4. Kit^mal plantar nerve. 
6. Il* deep division. 

6. Afc«Moritu muscle. 

7. Digital brunches of internal plan- 

tur nerve. 

5. Toodon of perouous longus. 



y. Flexur brevis hallucis. 

10. Superfii'inl division of 

plantar nerve. 

11. Adductor tmii'-v' ' 

12. Flexor brevis III. 

13. Adductor oblinij' I 

14. Interosseous muscles. 
16. Two outer lumbricale*. 



exteroal 




THE KUONT OK THE l-RO. 



idi 



verow ImlliiriK, uinl Ui all tlic iiitfriLvtrnim niiim'1i-><, except tlinwij 
of tlie fourtli or uuU'iiHont iiil»i-i>»>.i'0\i>< »i)«it', wliirh are itupplii 
by llii; iiu]H.'rliciul purtiuii, und the two itiuvr dunnl inluroit«<!i,J 
which iiaually ivcfive tlicir bramhi-s fmni the imti-rior libinl. 
I The Fourth Ijayer of Musdas ouiiAiBtit ul' tlit: pliuitnr iiiUr- 
ej, which will '"■ !■• it. r -.-.n when the tldnuil interowei uru 
diam'cted. 

iMtuM iiK ■IMK Lril ANII FlMlT. 

. [The nkiii reiiiaiiiiti^ on ihv front iirnl nutcr hIiIi' ul' (lie lej; uml on 
l«rk of the fiKit id In Ik" rfinovnl, iiiiil thi' MiijHTt'n-ijil Veins uuii 
v«r» iiiw-c("t«d out o( the Mijii-iliciiil t'iij>citt, ultei wliiih the rluep 
'Ihacia thimld be clraunl.] 

Ttic Superficial Veins form an urdi iicroM the buok of thi- fiHit, 

pTuling ill the int<Tiiiil und i-xlenml ■Mjphi'Uonn vrinii on 0]ipi'i>ili- 

Th<t iiiUniul Miphtnout iri'ii in td lie tmcvtl fmiii the innu 

i the doimd iirch upwiirdu in front of the interunl nudh-olu 

IKwlerior part of the inner kiile of the knee. The rrtemal 

'■lilt vfiii ji(D*«K« from the out<T Mv of the urch Lvhiiiil the 

exl«niiil nmlleolun to the niidille of tlie W'k of the U'K. 

CutaseouB TServea. — On tlie outer »ide of the leg arc a f«w 
cata»r-oii8 bruni hes from the eiUrmit yopHtad nerve ; and on the 
inner side fmiu the long wpheiioun. 

The MuBcuIo-CutaneouB Iferre (Kig. 1)4, 13) jiiurcM the devp 

ci* uIhjuI till- lower thinl of the outer side of the front of the leg, 

jii*l Wfore or iifter doing so divide* into two portions. The 

Thtenml divisidn (15) giveH braneheH to the inner aide of the itnkh- 

aiid fixit, iheu to the inner nide of the |,'reut tue, tlie outer *ide of 

• diid, und the inner side of the thinl to<- ; freijuently ivlno 

^ u Hiiuill bmnch to join the imterior tibial nerve Vittweon 

i*t lUid necond toes. The outer division (,t^) siljiplied the 

"ide of the third Ux-, both sides of the fourth, ond the inner 

aide of the fifth toe, and gives a coniniunicnting branch to the 

Kt«nial naphenouH nerve. In some caseti it« urea of dintribution in 

licrouched upon by the latter (Fig. 9-1). 

The External Saphenoue ITerve (Fig. 04, 2t) wind' around 

bo external malleolus from the buck of the leg, und n distributed 

the outer side of the little toe, or occasionally to both sides of the 

ttle toe And half the next, joining the luuaeulo-cutnneoufi nerve. 

lie Anterior Tibial BTerve (Fig. ;)4, 16) runs VMiieath the 

aular ligatueut and to the outer hide uf the dorsulis pedis artery, 

giving olf an artKiilar branch to the ankle and an exlenuU 

beneath tlie extetuior brevis digitormu to supply it and the 



192 



THE FRONT OF THK LEO. 



u 



tarsal niul tarBo-inetatorsal articulations, often presenting a p9endo-| 
ganglionic enlargement due to thickening of it-a dheatk Tb« 
terminid bniiicli ri-ceives a bmncli of coiiiinunii'^ition from the inntt 
division of the niiisculo-cutaneous, and is then prolonjjed upon I 
fii-st dciraal interoKseous to end by liifuroitiun into two digito 
bmnehes to the adjacent sides of the first and second toes, ton 
times nls^o supplying the fii>t nml second dorsal interosoei. 

The Internal Saphenous Nerve lies in front of the inb 
malleohiH with the intenuil rtajihenoun vein, which it accompania 
It nniy be tniced along thu innei' sidu of the fcKit, 08 far as the 
of the great toe. 

The Faaoia of the Zieg is dense and white, and is attached 
the KnK'utaneoua surface of the tibia on the inner side and to 1 
anterior and posterior cxt*.Tnal liorders of the fibula on the out 
side, forming intermuscular septa lietween the peronei longus 
brevis and the a<ljacent inuRcles. It gives origin to muscu 
fibres at the upper part of the leg, where it should therefore 
allowed to remain undisturbed ; but the rest should be remow 
except a thickened Wnd over the ankle joint, the anterior auuiU 
ligiiiiirnt {Fig. 94). The anterior annular lignme'-t consists of t* 
ports, one passing from the tibia ti> the libiila, and having a sep 
compartment lined with a synovial sheath for the tibialis anticfl 
tendon, wliite the rest of the structures ]>asa l>enealh it ; the oti 
being attiched externally to the upper surface of the os colcis 
front of the ciilcnneo-nstnignlar iuleroi'seous ligament, and reach 
interiKilly, by two mure or less distinct bands, the inner malleolll 
and the iiuier row of tarsal bones. This latttr portion liits three con 
partment.s lined by synovial sheaths, for (1) the tibialis (iniio« 
(2) extensor lougiis hallucis, and (3) extensor bmgus digitoruin 
pcroneus tertiua ; the anterior tibial vestiels and ner\'e ]nis8 bene 
the ligament, and are cros-sed superficially by the tendon of 
exf<-n.sor longUB hallucis. A similar band lietween the exl 
malleolus luid the outer surface of the calcaneuni is called 
ejrternal nnmilar liriamntt, and encloses the tendons of the pcroneU 
longus and brevis at first iu a single sheath which, afterwards, f 
divided into two on reacliing the peroneal tubercle. 

The internal anmtlar luitimnil jiassing from the inner malleolll 
to the calcaiieum has been described (p. 179). 

[After defining the nulerior annular ligament, the fascia is to 
taken from the muscles nn the fiimt of the leg, and the latter; 
together with their tendons on the doi'sum of tJie ftMjt, as well i 
),he vessels and nerves, are to be cleaned.] 



EXTENSOR LONQDS DIGITOHUM, 



198 



The ExtenBor Kuscles (Fig. 93) are the til>inlis aitticiia 
iniier ude ; the uxteiisor loiigus digitorum with the jieroneus 
Ott the outer side ; nnd between the two, the extensor 
bilncis, appearing below the middle of the leg. 

The Tibialis Anticus (Fi^'. 93, 3) 

mtet from the upper twl>-lhi^l8 of the 

(inter Burfkoe of the shaft of the tibia 

ud from ita outer tuberosity ; from the 

inner half of the interosseous ligament 

(w the same distance ; from the fascia 

wwring the muscle, nnd from a sep- 

tiiffl prolonged between it and the 

utcn.<or longus digitorum. The librcjs 

wl in a brmul tendon, which becomes 

Umwer near the ankle and pa!t8c.s 

t^ngh the most internal diviHion of 

lie interior annular lig.iment, to be 

<««rt#' into the under-surface of the 

internil cuneiform bone and the Ixise. 

illhc metatar»id Iwne of the great U>e. 

JiutWure its insertion it grooves the 

UitOT fide of the internal cuneiform 

W. The tibialis anticus is a dorsad 

Juor of the foot at the ankle-joint, 

"i'\ m adductor at the talo-calcjineo- 

wl joint. It is one of the muscles 

*^'"u is often divided to relieve the 

'win of club-foot called ' talipes varus.' 

u ti utpplitd by the anterior tibial 

Tbe Sxtensor Iiong^uB Digito- 
"UnfFig. 'J3, 4) arincji from the upjier 
""w-fourths of the anterior surface of 
">< (ibala and for a1)out an inch from 



on tlie 
tertius 
longus 




Tig. 93.— Miurle* of the front of the leg (from Wilnon) 

QuKlriwp* extensor inierted into 

the patella. 
Sutxutuioout surlue of the tibia. 

Tibiili. unticun. 

■ 'liTitonim. 
Imlluds. 




9, 9. BorJeni of the «oleui muscle. 

10. Part of the inuer belly of the ga»- 
trofiieiniLia. 

11. Exti-iis'ir brcvio digitorum : the 
tendon ill front of thu figure 
18 tliiit ff tUo peruucus tL^rtius ; 

tliitt bt'liind it, tbu piTuiioui 
brarii. 



194 



THE FRONT OF THE LEO. 



the adjacent part of the interosseous niembiane, from the ou 
tuberosity of the tihia close to the tibialis anticus, from the fai 
njKjn the ui)per part of the iniwcle, oiid from the inter-niiiwuta 
septa on cither side. The muscular fibres exteiul nearly as low a* 
the annular liganieJit, through the outer division of which 
teadon pnfses, and at once divides into four for the four »r 
toes. The intfrlion of the extensor into the toes ia similar 
that of the extensor of the fingers, but ou a smaller scjJe. 
tendon forms an expansion on the back of the lirst phalanx, i 
is there joineil by the tendons of the convspouding inter 
muscles (but seldom by the lunibriciili8),and in the case of the sccon 
third, and fourth toes, by a tendon of the extensor brevis di^ 
toruni ; it is tlieii continued forwards, and divides into three pnrt.i. 
the central portion goin^; tn the second phalanx and the lateiil 
litronger pieces tti the tliinl ph-ilanx. Tlie miinv of the exteiu 
longus digitorum is to draw up the foot at the ankle (don 
flexion) and to extend the four outer toes, chielly at the inetati 
phalangeal joints ; the interossei being the ]>rincipal cxteuson 
the middle and luigual phalanges. (Compare tlie description u( 
the fingers, p. b'5.) 

The FeroneuB Tertius (Fig. 93, 6) is often a part of 
extensor hrngvis digitorura. It arisei, below the extensor, from 1 
lower half or two-thinls of the anterior surface of the tibula | 
slightly from the interosseous membrane ; and from the septu 
between it and the peroneus brcvia. Its tendon passes through I 
same division of the annular ligament as the extensor longus digili 
rum, and is inanifd into the upper surface of the base of the tiii 
metatarsal bone, close to the Lntermetatarsnl joint. Its artinn if | 
assist the extensor digitorum as a dorsal llexnr, and to abduct 
foot at tlie talu-i'alcnneo-sciiplmid jijiiit. 

The Sxtensor Xiongue Eallucls vel Proprius (Fig. 93, i 
appears between the tidialis oiiticus and the extensnr dig:itonun in 
the lower third of the leg. It arhfx from the midtlle two-four 
of the anterior surface of the fibula, inteniidly to the cil 
longus digitorum ; imd from the adjacent part of the intemsjeoi^ 
membrane. Its tendon passes beneath the annular ligament and, 
crossing the anterior tibial vessels and nerve and the irL«erlion of 
the innermost tendon I'f the extensor brevis digitorum, is insttitd 
into the base of the terminal phalanx «{ the great toe. It is joinol 
opposite the proximal ])halaiix by exiwnsions from the phintat 



* It is usually siiid to ariw from tlio loner fourth only, but its fihn* i 
I mo«t eaaoB b<- found blending with those of the long extensor high in the 1 




THK AXTKHJOK TIBIAI. ARTEIIY. 



195 



L 



luuHcles o( the )m-at tot-. This iiiuscle b an pxtcnaor of the great 
tiMT, and a duriuil flexor ui tlie nnklc. 

The Extensor Br«vi8 Dieritorum ( l''i|^'. !>:$, ii) i« the only 
muscle of thd ■loi'suin of ihv fiK>t. It aritft from the iipixr «nrfac« 
of the gruatur piDcvi** of tbi> o» calcU ; frr)m tli<^ )ntcn>«i)couit i.'al- 
c.r .mIokI ligiuniMit ; und from th*- lower iMjitk-r uf thi- iinterior 

ui iiiu-nt. It vivU ill four tenduiu, ihe thrve ciuttT ]uks«- 

ing (jbhtjuL-l_v ocroi* Ihi- foot to !« nuurli'il into Ihi- »wond, thitil, 
•ud fouilh trK-s, joining the gi-ni*ral expniisiou of the extnisor 
tendinis ; the inii«rmo«t ^lip jimv^ing to ii gvpiimlo iittiirhmcnt into 
the biute of the ])ru.\imal phalanx of the );reat toe, aftvr croMinx over 
ike dorsal artery of the foot. 

The innernixr't ]>i)rlion of the niti»cle )•) a nhort exteniior of tlie 
great toe^ nctin^ with the lon)( extennor iii>on the proximal pbahinx, 
and «>'■'!'-<'' "■ -li'jlitlr in adduction at the metatatvophiUangeal joint. 
The ' -ef^nent extends the second, third, and fourth 

toe«, iinj>]u< in< iiiing Uic long extensor more eiwcntially when thi* 
uiuade Ik relaxed during dorxal llexjon, 

The hvc mUHclen liwt described are all tn/iiilinl \>y the aiiterioTJ 
tibial Of rvc. 

The Anterior Tibial Artery (Kig. U-l, 2) is n branch of iJie 
popliteal, and renoiu-r the Iront of the leg by pi<'rcing the itilcr- 
OWCOtU lliombnuie betwi'en the two heaiU of the tibialis posticn^d 
and htluYf the ]Hip1iteus. Its direction is from a point midway 
l)etw«Kii the Inner tulx-ruxity of the tibia and the he<id of the Hbiilti 
to the centre of the insteji. It lie* at l\r»t iijMin the interoxHtioual 
incmhmne l>etween the tibialis unticu>t and extensor longus digitoruni . 
and then between tlie tibialis antictm and extensor pruprius hallucis; 
in tiie lower ])art of the leg it winds on to the tibia, mid beuoiiieH 
■ujrt-rticial above the ankle-joint. It pusses beneath the annular 
U^unent and is crotxil by the cxtvnxor longus hallucis near the 
level of the joint. Its I'ontluuation ujmn the foot is known under 
llir tumie of ilorwlu jiet/i* (|i, lilt!). 

It is accunipunied by two rour cumitt* ; th<' anterior tibial nerve 
runs to ite outer side ns far ua about the luiddle thtrxl uf the leg, 
then lies in fmnt of it, but again gets to its outer side in the lower 
thinL A buuUI lyiuphalic gland is sometimes found uloi4e to the 
artery about the middle of the leg. 

Surgery. — The anterior tibial ortery may W- readily tied al.>ove the 

siikb-. l.v <in incision three inches long upon the outer side of the ten- 

I iFie tibi!ilii< autiriis «ud pandlel to it. The artery will Ije found 

liie front of the tibia l>etween the tendons of the tibialis anticim 

Aiiil the cxt<sutior projiriu* ballucis, with the nerve to its outer side. 

2 



196 THE FRONT OF THE LEO. 



■ITiprr 



u'u- 
II 1« 



The ftrtery may olao l)e renched on the deml l)OfU- ■- 
part of its Loui>e, Imt it lies so deeply liclweeu llif n 
(iprmtiou is selilum, if ever, undertaken on the livin 
iiulisliiict white line, iudiculing tlie position of tli' 

Bcpluin, sonietimeit marks thi' outer bonier of tln' ik 

well to make the incision a little ohliiiuely and not le** thau fnur 
ini.'he8 lon^, lie^inniug about one inch helow the liead of the fitiiiLi, 
at a jxiint midway between the bone and the outer tubertxity of tht 
tibia. The fiu-cia shoidd be divided in tlie wiine direction iw the itin, 
when, if the fore finj^er is introduced into the wound, it will prfl"! ' 
pass into the cellular interval between the two niUMcles ther>- ' : 
110 intermuscular septum to j^iiide the oi)eiator. The tibi.^ 
and extensor digitoruui must be drawn apart, luid the .. 
lie found ujionthe interosieous membrane with the nerve to its uuw 
side. 

Branches of the anterior tibial artery in front of the leg ; — 

The anterior tibial litotrreiit arises as soon a.s the artery rv.i ' 
the front of the leg, and winds through the tibres of the til. .; ■ 
anlicus or exleiim.irdigitorum to the front of the knee, to ana5t<jmu« 
with the articular arteries. 

Muncular branclu'js to the adjacent nuweles arise at various pointu 

The Malltolar artcrie*, internal and external, the latter liciiij: tiic 
larp'er and more constant, pass beneath the tendons to the inall> , 
in the neighbourhood of which they are distributed. The «<<<..." 
anastomose* with the anterior and posterior peroneal arteries, uul 
witli the tarsjd branch of the iloi-salis jieilis, the internal with th»i 
internal malleolar of ihe ]>ofiterior tibial artery. I 

Two Binall brunches are usually to lie found arising from thai 
artery before it jiiercea the interosseous membrani!, the jxMteriin- lihitM 
recurretit, passing over the back of the head of the libula, and ihfl 
tnperuir fibular, passing outwards over the neck of the bujie (p. 177)1 

The Anterior Peroneal branch of the peroneal artery {p. 178M 
apijears between the tibia and tibula through an opening in thm 
lower part of the interosseous membrane, running ujion the antericfl 
inferior tibio-libuhu' ligament and beneath the peroncus tertiiu tfl 
supply the outer malleolus, and to anastomose with the ejctenill 
malleolar and tarsal arteries. The inferior tibio-tibular joint tbJ 
sepaiutcs the anterior and posterior peroneal arteries, I 

The Sorsalis Pedis Artery (Fig. 94, 12) is the continuations 
the anterior tibial G-oiu the ankle-joint to the Viase of the 1st metal 
tArsal bone, opposite which it divides into the communicaling Ijnuufl 
to the sole of the foot and the dorml artery of Iht ijreat tue. IJB 
direction is from the centre of the instep to the first intero&seoJ 
space, and it lies at tii-st superlicially between the tendons oftH 



THE ANTElllOR TIUIAI- NEHVE. 



197 



►xUn)«or pit>priun jiollicin and llii- oxtvimor lungiH digitonim, but in 
CTo>«»".-<l livuT llii' {Hjuit of liLfuM-uliou liy tlii' iiiiionijdHl U-mlon (if tin- 
extcrirxir brevi* ili^'itunim. It lie* u{H)n tht' iiHtriiKultr4, i)i'a|>hoid 
and middle ninrifuriii Ixmes and thi-ir dorHul ligiuucnts, und hn« the 
antvriur tiliinl nerve to it« outer lidc-. Two vrmt eamitti accompany 
the vessirl. 

Surgery. — The dorsal artery tuny be tied in the upper part of 

itn courve by uu inoiiiiiiii on lite utitvr mde uf, but piimllel lo, the 

twuion of tbe i.'Xli'U"i>r propriun pollici«. It occHniDiiidly Imppfiin, 

i-r, thiit the nrteiT ix diopluced to tho niiddlii lA llie foot 

li thr tuiidcKi* of tiic exleUfor digitonini, "^v-i <•*«- 

Branches of the darsalig jictlis artery. c''^.. , , «._««.a4 

A fo»' suiidl unnaii)e<l turnal branche.s spring from the inner -i- ■ " 
tb« veHMel and ftniiht4Jiiiiise with llie internal plitntjir. The Tamil 
■riacM Injiu the outer nxle of the ve»Kol immediately below ihf unuuliir 
ligameul, nnd erosses the foot beUeHlli the exteii'ujr brcvij) cligitnrum 
to oiMitomoM.- wilh the urterien nbout the exteniid miiIh-olu«. 

The Mdatarml urtmj lvri^eJi lower thiin the ]iiece4liiig iiml near 
tbc bDM» of tlif mctiiliir.^d lioncs. It nUo riniH outwordH baueulh 
the ext<>n*or breviit iligitonini, ami givva otf three iiiUroiaeoic 
bnincheM to tho outer i>]Miec». Thc»e run forwonl uiwu the dorsal in- 
terr'Tisi'i u)mH.'l«(t, und bifurcate ut thu riHit« of the toes to supply the 
udjuceut NJdeii of two toeti eiieli, the outer uue giving otf n brnnili 
also to the outer nide of the little loc. The iintcrior nnil ]lO^^•rior 
perfunitint; iirli-rics, derived from the pluntur ofi'h nnd it8 ili|.;it;il 
\>i in ihi-M: intcrtiweous artcrieii near their originn an<I points 

f>' wft, 

I tirnnch pnwtcH between the lieods of tln' first 
upicle to the milu of the foot, where it jiunu the 
pluntur arvh ^p. l(<4j. 

The Donali* luilliuit runs forwnnl upon the greiit toe and, after 
^ving • bmnch which posMW to it/i inner Hide bcnenth the long 
«Zten*OT tendon, bifurcatet to supply the adjacent aided of thu first 
and aacnnii toes. 

Tho Anterior Tibial Nerve (Fig. !)4, 4) ia n bmnch of the 
cxtcnuil popliteul nerve ; it runs obliijuely aiuund tho out*'V side of 
t!i the tibulu in the til>re« of the peivneus longux, ulid reaches 

tl. I libiul iirtery by piercing tlie extensor louguti digilorum. 

It lii- l". the oulw »ide of the ortery in the upper jMirt of the leg, 
but in fr<'<iit of it about the middle, und reucheK itd outer siilu 
in at the aiikle. Its muscular relations nru tbe same its thorio 
'(Of the artery, wilh «'hich it posKes under the annular ligoiuuut. 



198 



THE FRONT OF THE LEO. 



In the leg it supijlies tlie four extensor muscles, sunl as soon wl 
entti'8 the foot gives a filftiiiunt to the ankle-joint and ilivide* inU 
two Iminches, Tlie unla- branch (19) is distributes! to the eitcu 
brevis digilonuil, thu iwX doi-siil interoeseMUK, and theaiticillation«( 
the tanuil and tarso-metatarxal jninti 
having a j)seudo-ganj;liform ihid 
ening of its sheath ; the iiiirfr 
(16) liea to the outer side of 
dorsal artery, supplies the Ist ( 
interosseous muscle, and becomia 
'■utiineouii is diiitrilmttd to the 
jacent sides of the great anil atcoQ 
toes. 

[The peroneal muscles are to be 1 
po«e<l on the outer side of the leg! 
iHinoving the fascia covering then 
when a strong iutenuusctilar ^eptu 
will lie iiiund on eaih side att<icha 
to the tibula, separiiliug them froo 
the muscles of the flout ami Iwck 
the leg. A pjrtion of the fascia is to 1 
left below the malleolus to form an e»- 
ternal annular ligamint.] 



I'ig. 94.— Deep diiaectinn of tbe front < 
leg (fruiu Uinobteld and LeveilU). 

1. Kxternal jiopliteal nerve. 

2. Anterior tibiiil tirtcry. 

3. Musculo-euliuious nerve. 

4. Anlenor tibiul nervf. 
■5. Peroncus Iuuk'ix* 
C. Tibiiilit iintii'iu. 
7. Kxt**ni*or lon^s digitonini. 

5. .Vnteriur iiiniulur liijuiuent. 
9. P«roiieu» brevis, 

10. Tendon of extrusor pro|)riu« ballucib 
U. Kxtciiri)>r |)ru))rit]s hatlucis. 

12. DiirMil iirterv of foot. 
!3, I'oiiit at wliicli mu«ciilo-cul:tDuoiu I 
picTceit llie faacia uud divider. 

11. TiMiJon III tilii:ilia antii'iu. 

\i. Internal biunih of niusculo-eutaae 

nerve. 

IC. Cutauuousbranoh of anterior tibial n« 
17. Eitemiil branch of luunculo-cuh 

nerve. 
19. Deep brunuh of anterior tibiul ner 
21. Kxturnal iaphcuoiiD nerve. 
23. Extensor brevi,i diKitotum. 





THE EXTERNAL POI'LITEAL NEKVK. 



199 




?eroneua Ijongus (Fig, U'i, 7) ari*f* slij^litly fruui the 
outer tuberosity of the tibia ; from tile L«ttil ami upp»;r twu-tbinU 
t>t the outer mrfai-e of the llbiila, ito orifc'iu iu thi- luiddlK thinl lyinj,' 
lichiDil HiAl of tlie jHjnrutun brcviK uiid ovi-rhippiiij; it ; from the 
intermuscular Mptutu uu each side ; uiul from the fimciii cowriiif; 
it. It ends iu a «trun); tc-ndon, which lien .-<u[>crticiiil t» that 
• if till? pcroncus bri-vis mid runs iM-hind tin- eitoriinl nmllt'oluii 
and under tlic external iinniilnr ligunn'iit, and then |iiuv-e» in a 
wpamtc «heat}i uf fu»eiii idon^; the nuti'r "id«< of the on culein behind 
the pcnmertl tlilKTi'Ii- tn tviuli (he cubdid lione, uruuiid which it 
turns to the kole rif liie fu<it. In the Nile the tendon runs ut lirnt 
liver a facet beneath the uutcr border of the ridge of tlic culioid, 
tlion lien iu the ^love of the cuboid bone and in an oa«eO'f)l>rou« 
iitli, and in intatfd into the lower |iart cif the outer side of the 
of the fin>t mrtatamnl lione, and 8oiuetiuieii also iuto the 
rnl part nf the interuHl cuneiform. The oheiith of the tcndun 
oriui'd sujierllciHlly by libreB of the lon^ phintar lijfiinieiit, and 
[lined with u biirMil uienibrane. The tendon hiiii u wiuimoiil 
tilage or bone developiul iti it* libn-n where it tiirnd round the 
order of the culioid Imiir. 
The Feroneu* Brevia (V\^. HZ, 8) lies beueutlt the p«ro- 
k longu», and ariurt fr<ini tile lower two-tliinli of the outer 
Hu-c of the tibuk, it» iijiper part beinx in front of ilie lower 
fc of tliv ori}{iu of the {lei-oueuo loii^uii ; and from tlic inter- 
Btcular M-ptu on each aide. It runtii upon the lower ]>art of the 
Bla, and its t«udon wiuds briiiiid the external malleolus, where 
ll lodged in a fjroove beiwath the tendon of tin- pcroneiiH longuji. 
Bllien rimH along the outer »ide of tlic iw <'alcii« in a Hheuth of 
■ia in front of the hmg tendon nnil |ieroneal tuljerde, and in 
■rtnf into the most proiiiiiamt part of the tuliero«ity at the Ijakc 
Hie lihh nii'tatarsMil Imue. 

uhe peiuiH'i act an ]ilantar tlexora uf the foot, t.«,, they point the 
B. Both niUMcleB, but enjiecially the piToneus longlis, alxluot Uie 
B at the tiUo-caU'iuie<i-8c'a|ih<iid Joint, and the peroiiriix longus in 
Bition fortuK un important iliiigonal tie for the longitudinal arch 
Klhc foot. The peronei are sliortiiied in the form of club-foot 
led 'talipes valguii.' B(ith an- mtyplied by the nuMculo-cutoncoini 
Br». The synovial niembraue luider the annular liganioiit is 
Binon to the two i>eronei, but it diviiles into two ]>art« oa the 
PwODfi approach the ivroiieiil t iiberck- of the culconeuiii. 
I Tile External Popliteal Nerve (Fig. t»4, i) is to lie followed 
mng the inner bord«-r of the bice]i!* tendon into the llbres of the 
■oneus longus, to which ]ioiiit it wm traced in the dinsection of 



200 



THE FRONT OF THE LEG. 



m 



the popliteal B]>ace. It gives off an external patellar eutaneout branch 
to the outer side of the knee-joint before eutering tlie mtiecle, mi 
afterwards a recurrent articular branch, which pierces the estei 
longus digitoruiii to leach the upper ]>urt <>f the tibialLi aiiticus uA 



Fig. 96. 




the front of the kuee. It then divides into nnlmor tibial (p, 197 
and muwnh>-eiitaneom (3). 

The If uBculo-cutaneous Iferve gives branches to the peruneiu j 
longUB and ])eroneuB brevis, and then aj)peaiti between the peroneukl 
loDgus and extensor loniTua digitoruiu, finally becoiaiug cutuneou»| 
by piercing the fascia in the lower third of the leg. 



Fig. 95. — A BectioD of the right leg in the upper third (altered from Bvnod) J 



1 . Tihiali* poiticua. 

2. Ilbiolii anticus. 

3. Fltitor longus di^torum. 
•4. ExlrnsDr longus digitorum, 
b. Internal HophcDuuK vein. 

C, Anterior tilJial TOiafU and nerve. 

7. Tendon of plantaris, 

H. Peroueus longua. 



9. I'oatvrior tibial Tesael* and nerriL j 

10. Flexor longus haU\u'ii. 

11. External saphenoua vein and 

UtTVC. 

12. Soleus with fibrous intersectiou. 

13. PHfoneiil vcmpIs. 
H. Gn»trocni-miu». 

16. Communicani peroncl nerve. 



THE INTEROSSEOUS MUSCLES. 



201 



iTbe teudon» on the back of tlie foot are to be divided or held 
., anil the trunsversns pedis in the sole is to be removed to 
iiit a clear view of all the interossei.] 

JBeneath the tninsveraua pedis will be found the plantar trantverte 
I of thf mtlatarsut, from which its fibres arise, and over wiiich 
I digital ve:^el8 and nerves pass. It ccuiiiects the lieada of the 
melatankl bones together and crosses licneath (on the ])lantar side 
ji\ the tendons of the interossei muscles. Tlie dorsal tranxi-erte 

Fig. 96. Fig. 97. 



(kiit- _ 




much weaker than the last, join the doi-sal nsijiect of the 
lof the uielntarsal bones and between the Iwn ligaments pas* 
■tcnilons 'if the interos-n-i as in the hand (we p. 89). 
Tlie Interosseous Musoles are seven in number, viz., four dorsal 
""d three plantar, the former being between the bones, while the 

^t- 96,— The doreal interotacout mutclps of the foot (J. T. Gray). The figures 
refer to the seven Bjnovial inenibranes. 

Fig. 97. — The plantar intcroMcoua musclea (J. T. Gray). 



202 



THE KNEE-JOINT. 



latter lie ruther on thi'ir under Rurfaces. The dorsal are bip 
form muscles and are seen ou bolh surfaces of the foot ; the pL 
ore seen only on the sole. 

The four dorsal iiUeroii»et (Fig. 96) arUe from the adjacent sidet 
of the metatarsal bones in nearly the whole length of tlieir slm 
and are inserted into the buses of the first phalanges in such 
manner as to abduct from an ijnaginary line prolonged thr<.mgh tlid 
second metatarsal bone (instead of the third as in the hand), i 
into the extensor tendon over the proximal phidunx. Thua tb^ 
1st is inserted into the inner side of the first phalanx of the secon 
toe ; the 2nd into the outer side of the first phahinx of the seco 
ti>e ; the 3nl and -Ith into the OK/cr sides of the thinl and fourth toe«l 
A portion of the 4th is very conspicuous in the dii<sectii>ii of the«oU;j 

The three plantar inlcrouci (t'y- ^~) 'trite from the inner aides i 
the thiixi, foiuth, and fifth laetaUirsiil bones, and are imerted inti 
the correajX)nding sides of ll>e lil'st phiUangea of the same toes aiij 
into the extensor tendons. They thus act as adductors towards i 
eccoiid toe. The priiicij)al uses of Ixjth dorsal and jilantar inter 
are, however, as in the liand, to Hex the proximal and extend 
middle and lingual phalanges. They are supplied by the deep brand 
of the external plimtar nerve, except those in the fourth space, whid 
receive a broiuh from the superficial part of the nerve, and the twoj 
inner dorsal, the branches to which come from the anterior tibioL I 



The Knee-Jolst. 

The knee is an example of u modified ginglyiuus or hinge-joinl,| 
The hinge movement between the femur and the tibia takes pLio 
around a shifting tiunsvei-se axis through the femoral condyles, aiii 
is compliciileil at the end uf extension and at the beginning of flexioa 
by a slight rotation around a vertical axis passing tluough th 
middle of the outer facet of the tibia. During flexion, the 
laxation of the ligaments permits also movements of pronation an 
supination of the leg around a vertical axis passing through tb<j 
inner tubercle of the tibial spine. Ita synovial membrane ia I 
moHt extensive in the boih". 

The knee-joint has in front the patella and ligaraentnm patella 
with the expansion of the extensor muscles and the fascial band 
(internal and external jialellar ligaments) which help to form iti 
oipsule. Behind are the po|ih"leal vessels and nervea and the 
branches, some lymphatic gliiiids, ^vilh the two heads of ihi 
g;tfliiicnemiuH, the plantaris, and the tendon of the popliteus. 
intitr side of the joint, near the back, are the tendons of 



THE KXKE-JOINT. 



203 



Mrtorins, ^jncills, M-mi-limiinojius, uiid siMui-iinMuljnmomia, with tliu 
long aaphmous vriit mi/1 iit-rvK and ii braiich of the uiui»toiiiutica 
magUi ; oiul oti the outrr aiih; the Ijici-jiM, with the rxtcrnul |iojilitca 
ll«rv», .->ci-ii]>ic« n hitiiihir |ii>sitii)ii, oiiil the iiiferiur cxtrriuil mtinj- 
\.\: '11 tilt' uMi'iiuil «eiiii-luimr cartilage iuhI the 

t> ■ riln. 

'1 he knee i^ llfj-ol hy the l>ic«j>(i, •eiiii-iiK'inhraiiOsim, xMlui 
tciidinusu&, ^rut'ilU, sortoriuii, i«Jl>liteU*i, xii^lr'niieiiiiu", utnl jiUinturiil. 
It is extended by the qiuulriccps cxtciuor. J'roiuilion in ulTeclvd by 
the aemi-meutbranosiiii, M'tni-tcndinuiiuji, graciliii, tuirtoriua anil 
)ioplJt«tt> ; Olid lupination by the bicvps only. 

The ligauiente of the knee may oinveniently Iw diviiled into 
extm- and iutra-nrticiilar. 

The Extra-articular Ligamenta ure [)usterior and htteriiL 

The Anterior Ligaments (Kig. !Jfl) iire represttnted by tlie 
jiab'Ila and tlii' / ''r: in the middle, and the I'XjMinitiiiiui 

of thf v:i>li utid I lUieiiU on either fide. The fsitrnal 

y' '<iir>i/ IS ii |iroci'>« ol the ilio-tibijtl buml nttiirhecl t<i tho 

n;i I' r of the boau Iwluw the viv«tii« vxternuH and to the 

U^mrntuni putella;, while the mlenial [Kilnllar Ui/aineiit, derived 
fiunt tile Ititenial iiitcruiUKCulur nepluiu and iuiiur tuberosity of the 
(einor, in eiuularly cnancclod on the iutier aide. Some deep 
BUp|denirntary tibrc* inay nbo jmiih from the tulierositiia of the 
tibia to eitlier <dde of the ]>ntella, and it uliould lie noted that the 
patellar attachnient of the vaxliii) inteniuii extcmlf hiwcr than that 
of tiie vastus externuH. ISetweeu the li>;iunvt>lum {lat^dlw and the 
upper part of the lulwrcle of the tibia i« a luirna (/jurwi mub- 
fottllnrit), which must not be cotifounile<l with the prosier burmi 
la in fn>nt of the bone. 



pr^' 



[Til M-e the runmiiiin;^ 



\lriiiid liyaiuento, the popliteal veMeln and 
ui-r\°ea and the remains of lln- pixtrocnemiu'i and plan^l^iH initxt lie 
removiHl. The tendon>i of the biceps, iienii-nienibrnnosua ami |H)pli- 
Icun ari' to I* ttwril out fully, and ."hould U; cnrefully prenerved, 
li': ' .rt. The internal Inter.il lix'atiient will be liiund to be 

II I with the capKule, the exlernul is beneath the tendon of 

till' uui'i'- aud external |>utellar ligament, and is ii<>t 'M'en Ulitd these 
]iavc been divided,] 

The Posterior liigament (Fig. 'JO, 8) (ligiiineutuni poiitionui 
WlDslowii) is a llat baud, attached above the cuudylua uf the 
femur onii to tlie bock of the head of the tibia ; it \a closely 
cuunectcd with the. tendon of the xemi-meinbranoaus, from whieh 
a lur^e banil of (ibre.i pa'ses oblinuely upwards and outwiinls 



20+ 



THE KNEE-JOINT. 



ro88 the back of tin; joint (Fig. 99, 13) and on tbe out«T side 
'Weiveii a «lip from the uliort external lateral ligauieut. It 
extremely thin beneath the heads of the gastrocnetuiiis, ami 
fre«iuently perforoted where the inner head of this uusde an 
the semi-memhranosus tendon are separated from the back of 
internal condyle by a buna, which in this case coniniunicates wid 
the cavity of the joint. 

The Bxtemal Lateral liiganients (Fig. 98, 5 ; 9». i) 
two in number, the lomj and slu/rl, the long being the unteHur OUO ( 
the two. The long liyamait in a round cord extending from 
margin of the giu-liocnemius impression upon the side of the 
ternnl condyle immediately above the posterior extremity of 
dejiression for the popliteus, to the middle of the bicipital till 
aity on the miter side nf the head of the fibula, l>etween thu dirisia 
of the biceps tendon and above the peroneus longus origin, 
tendon of the popliteus and the e.xtemal inferior articular 
pass beneath it. The thort ligament is placed Iwhinrl tho 
and reaches from the condyle to the styloid pn>ee33 of the fit 
blending with the outer part of the posterior ligament above ; and J 
connected l>y means of a ciirveil band (ligamentum p<>plit«a 
arcualum), which passes from the middle of its inner bor>ler to 1 
p<jslerior ligament ami to the tendon of the popliteus. Above tb 
lies the ]>opliti'Hl aperture in tl>e cajisule. 

The Internal Iiateral Iiigament (Fig. 98, 6 ; 99, i) i*^ 
strong bond closely connecteil with the internal patellar lignnii: 
lUid internal semilunar cartilage. It is attached to the mo 
prominent part of the inner tultBrosity of the femur aljove, and ! 
in more or less direct continuity at the ailductor tubercle with 
tendon of the adductor magnus. It expands as it descends, and m^ 
be divided into two portions, anterior and posterior, the poster 
attached to the inner tuberosity of the tibia and covering in 
tendon of the semi-juembnmosus ; while the anterior segment, 
fixed to tho tubei'osity, is continued on to the upper part of 
inner surface of the shaft of the tibia, leaving an intervid thtvug 
which pa-ss the inferior internal articular vessels of the knee. | 

There is rca,son to believe that the internal and long exter 
lateral ligaments are degeneratti tendons, the former of the addaci 
magnus, the latter of the peroneus longus (Sutton). 

The posterior and lateral ligaments aid the crucial lignmcnts j 
limiting extension. The lateral ligaments in addition check 
movement of supination (external rotation) of the leg that is 
milted during flexion of the knee. The caj>sule of tho joint is 
deficient where the tendon of tlie popliteus passes downwanla or«r I 



orerthe I 

m 



THK KNEE-JOINT. 



V\g. 99. 




Fi(. 98 interior riew of tlia lignnivnU of tha knw'joint (fiuia Happnjr) 

1. LigHiurtttum [uitrllm (ibfl lateral 



pAteUnr licarnciitit huvv bt'tfn 



2. r.i. 



• 1 by lifiiiUiii'iiB 
I (rom th« rectus 



HUU v»«tU 

3. TubCTx'le nf tihia. 

4. 

6. 



'ren.: 

l*.i. .1.1. 

6. !• • 

. 99.~Po»t*rior viflw of 111' !- u; 

1. Inl. r....! L.l.-.i.l 1. 1-. .,1. 

Ixit Minit. 

i! .Iliini. 

i . conni-ctfil 

V. ^ ii.iuli.) 

Tei.' n, 

4. I' i.rturc 

I- litliu. 
t. 

^6. J't .1 Ni'iiii* 
tuaahrnnutus. 



7. llloinltttl tubrnMlty of hcnil of 
Hbulii rr4;4avtnir iittBrlimeiit of 

I'll ■ ' ' • I ligament. 

8. In- 

9. Ten.' 

lU. Iliwrllmi III Kliullia. 

11. Tt'iidnn iif nilfUirtor mxniu pro- 
loui,'F<l iatu iutrniiu latvml 

Vi. lauTtion of turai-tcndiuMiu. 
i.'f of the kncc-jiilnt (from Sap[>ay), 

ij. Olll'-r I ! 'I' i-.-ir...., ,,,,, 

7. Inn. 

M. Pu»|. .l„w). 

fl. Oix'iiiiii; 111 ..aijjulc. 

lU. I'oHrriur •ujHU'lur (ihio-Bbuliir 
Itxitmi'iit. 

11. Timl.in of uililuctor mu;^iu. 

12. Ti'ndou of liicrpa. 

13. i'n>loiigiitioii from tendon of •rmU 

moniliriinosu< to po«tvriar ligu- 
mi'nt. 
I'l, Poaterior ligament (of VfltrnVowV 



TBI. KXEX^MHST. 




BCB i«lcn«lt«. 

the 

at Ike aMBo-latend j«iti o( 4i 



artkS^B 

. . II * 




rrb* ttaitmi fd the nctM k to be liiraicd and dnvn 
oMcr tn (BC tltr exlmt o( the ■rnorial laeMfccWM abore the 
«M> it ncoaUf rmdwc fer a coaple of iadMa aborv the 

t of tfar feflior aad giTM attaduBent to the Smbewitrrtu, a mull 
ariaiBg fioai tW !«•«« pn ^f the aalciior «ar&ee of tb 
iemir. In mnhc caae* thii iiIiimmii Wacalh the ^nadtierps formi i 
(liitiact bona aefuatcd boai the kaee^oiiit 1^ a aetata, aad ia 
utMtty caaea a little ojoatrietioii or partial iliaiaiaaBt U Ibaad iui 
al«ire the patella. The araorial man'facaaei* tJKn to be tliTiile>iwD 
each aile, aa atar the oauiyita aa poaabfe, aail the pitrHa im! > 
ilova, when the ligaia t uta an mnmanm aitd the ligameiita alar;. 
lie Kts.] 

The T-* !!:»"«■" *""» Xaoomtm (Fig. lul) t$ a pjnmidal 
tion of ■joarial nembiBiie a t tai chw i bv it< apex U> a depicaMB 
the aolch hetveea the cooiirlei, tmmwiiately behind the aitii 
aurface, From tiii^ pcrint it ezpandi encloaiiig a large quantity 
ilt which Uca agautat the back of the lower angle of the jiatella, llw 
HgftlTW*i iiii pateUie and the lateral patellar liguiuents. 

The Zrdgaawtita Alaria are merelr two fringes of srnorial 
IMmbnuie appended, one un each aide, to the lig-dmeutnm tnnrjMom, 
and mnning upwards as far a.« the lateral border of the patella. 

The ligamenta mucosa and alaria represent a septum which in 
onimaU, but rer%' rarelv in man, di«'ide« the knee joint into thi 
•egmeuta, a femuro-]mUJlAr and two condylo-tibiol (Sutton). 

[Til .:um mncfitium is to W divided nnd the patella tamfl 

dowii •, when Uie bureu of the litjainenlum patell.i; can I 

ii]>eri>-'i :iii'! -ceil. The cajisulur and posterior ligiiments are to 
immved, but the lateral ligaments are to be pivserved and 
cruciul li^ttiientii dici^Hrted.] 

The Intra-articular Ijigaments are the two crucial and 
transverse lif^nnit-nta. Within the joint also ui« two semilo 
lUirtilayi" wliich are jmrtly ligamentous. 

The Cruoial Ijigaments are two powerful bands exl 



TUK CRVCIAt. I.inAMKSTS. 



207 



Vif. 100. 



Um apper intfisinicnlar surface of the tibu tn the two atdoi 
' Um iiitier<on(}yloid notcli uf ttii! femur osd invc*tcd bjr • ptn- 
loagatioti of nyuoviiil nicmlirntic. 

The Anterior Crucial I>iffMn«nt I Ki^. i On, 2) U attathn 
•bove Ui tlie inner ainl (uuk jmrt of ih* extt-rnal condyle of ill 
SetaoT, and |iam><-k obliiiuily dnwnwanls, forvrnnl*, ami inwnrtla 
llw joint, to 1k> iii-<.*rt*«J into the 
epuc« on the top uf the tibia In 

Bt of the spiiie, between the anterior 
attAchmenl* of the internal Btid external 
aemilunor cortila^ci. It rcectA-c< a clip from 
the externa] semilunar cartilajpu. 

Tbr Posterior Oruoial lAgKment (PlK' 
\Wi, 3) i» br<uuler and xtouter than the an- 
teiior. It is attached f^ the antrjiur and 
port of the internal t<>ii<iyK', anil 
doimwanU, backwanU, ond >li;:htly 
ioVBRls, to the top nf the til'ia lirlwitrn the 
■ittealar foMtii and U<hind tlie >-|>ini-, And to 
tbe poplitMl notch. It iv<'<'jvt'« two i>|j|<» 
ftan tbe potterior extremity of the internal 
aaaiUnnBr cartiloK'i, and if closely cunnectol 
with the anterior crucial ligament at the 
point of dec uwation. 

The ir.ii i.tl liguiient* check cxtruaion and itsixt diidocation in ail 
dinxtiotM. The anterior ligament aUo limit* thi> movement nf 
pTMuUtoB (int<>mal rotation) nf thi' h-^t that i» {HTuiiiieil durinj; 
Htliett uf tlie knee. 

If the lateral lit.'amenti> arc now divided, it will be found tiuU 
the fri! ' become ni led thun before, abowii 

tlial tl. crucial 1;_ .- not Mni|>ly tn nuiintoia^ 

tiia oxttcular nutiViiri in apfH»iitori. it will aloo l<« wr-en that 
wkikt r.iitiriii of thf tibin niitwi.nl- ojvn now l(« carried to an 




t>i. 

1. Ontilapoou* ti^-' 

Minauty ui 



;it, .iiid ill^wx-ted to I 

* - ' . '''■ : . "III;. 

~ \ ■ ■ ' .n ir < .irtilijB, 

^ r I . im.iiium (latrllii) 

Ill' -KM I I. mi ii)i«rn. 

10. .Uitrtior •ii(imur tibio-libuUr 

birainent. 

1 1 . Interoairoai 1 



208 



THE KNEE-J01^r^. 



extreme degree (so as to bring the crucial ligamtnU «lino«t 
rotatiun inwards ia iminetliiitely dieiikeil by the tension 
anterior ligiuuent, and it i» thus that thi- ten<lency of the jiop 
uiUBcle to rulate the leg inwaKls is cniuUerbalaiiced. 

Fig. lot. 




Tlie Transverse Ligament (Fiy. 100, 4) is ii small band 
nectitiK tin; luileriur (.■xtiviuities of the two aeuiiluuar cartill 
ami often not distintl. 

Tlie Semilunar Cartilages (Fig. 100, 6, 7), which ciin lie p( 
eeen now, but will be fully expo.^ed by dividiuf^ the crucial ligunil 
are two fibro-caitiloges interposed between the tibia and fe( 



Fi(r. 101.— Vertical Motion of kiive-joiut (after Brnuiie). 

1. Svnoviid mnnbnine. 7. Siiml ve«8cl«. 

2. short heail of bictpa. 8. Poplitiid veiowU. 

3. I'liuneal iic-rvc. 9. Anterior crucial liguiuciit 
•i. Loug hmd of biceps. bursa Hubpnti'lluris. 

6. IMitatarie. 10. LiKumcutuiu pHtcllic. 

6, External Kioiiunar cartilage. 11. Bursa prtepatelluris. 



THE SEMILUNAR CARTaAGES. 



209 



TWy are triangiiLxr on section and present each twn free surfaces, 
niperior and inferior, turned towiinls the ft'Hiurnnd tiUiu rcipeclively, 
and an outer attathetl surface or base connected wilh the inner 
lapect of the capsule, aiid following the curvature, of the outer 
bolder of the corresponding tuberosity of the tiliia. They are 
filed to the tibia partly by marginal fibres (coronary Hganients), 
derived from the capsule, partly by the direct nttufliment of their 
6liru\u extremities to impressions in front of ami behiml the tibial 
•I'ilie ; and are also coniiecte'l to tlie interLomlylnr notch of the 
^taur l)y libruuH bands, which join the crucial ligaiiicnts. They 
^■Re tu deefien the tibial facets, and at the same time to form fur 
^%cli femoral condyle a shallow sooket, which is capable of adapta- 
tion in shape and jwsition to the surface opposed to it in all the 
liillerent nioveuieuts of the joint. Their uttrilmted function as 
I'UlTers cannot be important, as they are <leHcieiit at the point of 
ttuimum i-outact between the two bones. 

The Internal Semilunar Cartilage (Fig. 100, 6) is oval in 
foniL Its anterior extremity is attached to the tibia in front of the 
•iiferior crucial ligament ; its posterior extremity in front of the 
[n«t«Tior crucial ligament. It is less moveable than the external, 
twi i" more liable to tnuimatic displacement. 
Tlie External Semilunar Cartilage (Fig. 100, 7) is nearly 
;ulur. lis anterior extremity is attached to the tibia iimneili- 
ly in front of the spine ; it« posterior extremity behind the spine ; 
the latter is connected with the posterior crucial Ligament by 
or two distinct slips. It is less extensively attached to the 
margin than the internal cartilage. 
The popliteus is indirectly connected wilh the external cartilage, 
the semi-membronosus with the int^^mul caitilage, through 
•ttAchment of their tendons to the posterior part of the 
l«, and the curtilages are to some extent acted upon by 
Dioscles. 
Structures upon the top of the Tibia from before 
ikwarils ore as follows : — 
Transverse ligament ; 2, Anterior extremity of internal semi- 
curtilage ; 3, Anterior crucial ligament ; 4 , Anlcrior extremity 
Hlemal semUunar cartilage ; 5, Posterior extremity of external 
liluimr cartilage, separated from 4 by the tibial spine ; 6, Posterior 
f of uiternal semilunar cartilage ; 7, Posterior crucial 



Synovial Membrane (Fig. 101) extends for at least two 
above the articular surface of the femur, forming a pouch 
1 tLe extensor muscles. It is reflected from the niargma uf 



210 



TIBIO-FXBULAR ARTICDXATIONS. 




the articular surfaces of the femur and tibia on to the inner 
of the capsulf, and thenc« over the crucial ligninents ajul ov 
upper and lower eurfaces of the semilunar cartilages. It gives * 
tubular investment to tlie tendon of the popliteus where tliiB 1: 
witliin the capsule, and has alrea<ly been seen to form the li, 
mentuiu niucusum and ligamenta alariu : and email pouches 
be found on either side of the lower attachment of the postei 
cruciiil ligament. 

By means of its reflection over the crucial ligaments it fomu 
partial mesial septum attached to the capsule behind, and divid 
the joint cavity into two lateral halves whicli intcr-commuuical 
in front. In rare cases the septum is complete. 

The BiirsBB iii the neighbourhood of the knee (Fig. 101) are i« 
follows: — 1. The mhcruTeiit bursa, which extends two inches 
more above the patella, and is usually, but Jiot always, contiuuoi 
with tlie synovial cavity. 2. The poptitcuji burm, a prolongation 
synovial membrane which surrounds the tendon of the popliteus 
passes with it over the back of the external seiuihuiitr cartilage 
of the internal tuberosity of the tibia, and may e8tabli.sh a commii 
cation with the superior tibio-ftbular joint where the muscle 
the posterior tibio-libuliir ligament. 3. The yoMrocnriaiiu bit 
lying beneath the inner head of the gastrocnemius and the leuJi 
of tlie semttnembninosus, and often named after the latter muscli 
It sometimes communicates with the synodal cavity (roost fi 
((uently in nmle adults), probably in conseijuence of ubsorpti 
of the cajisule by long-contiime<l pressure against the back of 
condyle. 4. The anttfriar semimeir.branotu» burta, between ti 
tibial attachment of the tendon and the internal lateral ligsmenl 
5. The prfptUvllar hurtce (B. subcutanea, B. subfascialis, 
B. Bubtendinosa (occa-Hional) ). 6. The %nJrii-^>attUur buna 
tween the ligamentum pntellaa and the upper part of the ti 
tubercle. 7. The hireps burea, separating the tendon of the mi 
from the long external lateral ligament. 8. The mtrlorius 6ui 
common to the tendons of the sartorius, senii-tendinosus and gracilii 
This lies beloM- the level of the jouit. Occasional burace nmy 
exist in front of tiie tubei-cle of the tibia and ligamentum patel 
and beneath the outur head of the gasti'ocnemius. 



TrBio-FmuLAB Articclatioks. 



[The whole of the muscular fibres connected with the liones or 
leg and foot must be removed, but the tendinous insertions abo^ 
the foot should be kept to be examined with the ligaments.] 



TIBIO-KIBULAU ARTICULATIONS. 



211 



The Superior tibio-Httulnr articulation (Fig. BO) in a aimpU 
arUimtiial juijit, the synovial tucmhrnnr of wliich i* uccosionally 
coDtiiiiioiig with thai nf thr km*)' through tho mnliiim of th* 
|ioj>li(ral bursa. Thf antrrior ami juittn-wr (lo) ligiimenlji 'ar» 

Pic 10?. 




•Ijnrt > •;,' the anteriur unil pimtt-rior •»urfiiccn of the* 

hwiil ol M the outer tuhonwity of the libiii, ami forming 

11 ca|«nili', The joint is slrenglhcneJ l>y thi- trnilon of the l)ipep9. 

The Middle tibiu-lihular artivulnlion in formed hy the intrrrmtott* 
Uffonuat or merobnue, and ii thtr grcnt Ixmd between the Ahafts 



1. Posterior 

ligniuRnt. 

2. Truoi 

3. I'lwt' 



li-'iiiji n* 



tlio pxter- 



102.— Pa»t»riar ritw of thi- naklo-jntnt (from 8«ppcy). 
infrrioT tibio-6bular 8. Tiihfr ' ■ ' ', of Rroovn 

l"i in'in. 

it. Tcwt. ! : ii« r»lni», 

10. TiilHrriilti uit toiler sute of groovp 
for flexor Irmsiu iiollicin. 

11. Gr»x>vo un iiMtnijpiniM for flexor 

loilKlM {hllllvit. 

12. Posterior ciiluuiieo - Hstmgaliir 
liKttiiHmt., 

13. roinlofioMitinnnf tvoilo-AohiUii. 
P 2 



».. nil M).<ui>ent. 
calMneo - utniptUr 



iliiiiito liuoiruliu of axtcmiU 
lateral Ugomont. 






212 



ANKLE-JOINT. 



of the liones of tie leg. Its fibres run downwanlit frnm the tibia I 
the tibula, and are att«chetl to the sharp interosseous bonlera 
botli boneit. It is pierced a1x>ve by the anterior tibial vessels, and | 
near it« lowej jiart by the ant<;rior jieroneal vessels. 

Below the interosseous membrane is the inferior interoueou* Iv. 
mtnt, which consist* of verj- short fibres passing between 
triangular rough inijiressions on the adjacent »iu-fuces of the tih 
and tibula, inimeiliately abijve their inferior articulation. 

The Inferior tibio-fibular articulation (Fi};. 102) is a simpK 
artlirodial .joint, continuous with the ankle-joint. It has antri 
and poelcrior ligaments between the two bones, resembling thu 
above, and in addition, placed below the posterior and distin 
from it ; a tranxvfrse (or inferior) liyanunl which reaches fruml 
the external malleolus to the posterior surface and malleolus nf 
the tibia ; and the iiUerofseoiu lujiimriit just described. A fob! ol.i 
«ynovial mejjibrane is often prolonged for a very short distoua 
Ijetween the two bones from the anklejoint. 



Ankle-Joint and Articulations or the Foot. 

The ankle-joint u almost a pure gingljTtius, moving 15° (f 
the position of station), in the direction of dorsal flexion, and 45' : 
that of plantar flexion. It has in front from within outwards I 
tendons of the tibialis anticuH and extensor proprius hallucis, tb 
anterior tibial vessels and nerve, the extensor longiLs di^'itonim, awl 
the peroneus tertius. Fixing these structures in j)lace is lli 
aut<?rior annular ligament, and more superficially lies the in)iscul( 
cutaneous nerve breaking up into its intenial and ext*.-mal brancha 
lifhind, arranged from within outwards are the tendons of 
tibialis posticus and flexor digitorum longus, the posterior til>j 
vessels and nerve (or it may be the plantar vessels and nerves), 
flexor longus hallucis, and behind the external malleolus, the teudo 
of the peroneus longus and brevis (Fig. 103). The ankle-joint 
anterior, i>osterior, and two lateral ligaments. 

The Anterior Ijigament is a broad thin membrane which ; 
Behlom secji entire. It is attached to the lower margin of 
tibia, and to the superior surface of the asti-agalus, close to its I 
and joins the later.U ligament on each side. 

The Posterior Iiigament is not described by many autho 
and it is seldom represented by more than a few fibres atretchn 
over the sj-novial mernbmne between the back of the tibia iwd 
astragalus. 

The Internal Lateral Ligament (Fig. 104, i, z, 3, 4) I 



nU CUXUStGlVASTIUaALAR ARTlLTtJtTION. 



SIS 



ttwh rf lo dM dpMid bonlciB p( ilw wmsmU imUmIim, utd Um \ 
to iIm ftturim pnt of Om mUi^m, ika Immt |mc«m <if Um 
cakit, Ife infanaK ■■W«wwnf|i>ii>iKl tiyiawwr, mkI Um tub 

Ui^ , two aInM« WiMMial •lUcimi In Ui< Mtn|g«lttit uhl 



R»- lOS- 




runniat; duvnwiinl* aiul boi-kwonli to tho cm lUkici*. llio itn((n'<if' 

'<< fioiii tlin Aiitniiir lnitOiT of tin- fxttTiml malli'uluii h.> 

' tlw tt-lm^-nliii ill fiviil of till' iiiiilli'iilnr facet ; tho 

I «liicli ptiwi'it (lowiiwuhU mill UickwimU 

1 118 til iiii uiiiiiiciicr oil tb" outer •ulu of 

-. U'liiiid liiB iicroueul tiibeKlB; thi> ;>itf/rrivr (Fin, l<'|j, 3) 

» . I t.) Ibe ditji ifpmve behind the urliciibir HUrl'iu:!.' ot tbn 

cxtrmid nmllroliis, und ]iiihik« borir.nntally to tliv cxtcruid tiilMtrcU 
no the post<.-rior »urf»o.c nf tbr aiitra){nlu«, buhind the Ulilal fucvt. 
The CaloAneo-aatrAgalar Articulation bo« *uttnial, j'uthrio 



Vie. lOS.— Vcitloal tnntion of anklt-jMnt (»<Iot tltnl*]. 

6. Anlrnirnlo-rulcniiiMin U(nii)uiil. 
lieltuium. (i. lVt<)iioii> Urcru 

1 ipviii Imii^iji lulliitni. T. (>• imlvU. 

Aitmsvliu H. I'oroncui lon^ru*- 



212 



ANKLE-JOINT. 



of the bones of the leg. Its fibres run downwards from the tibia 1 
the fibula, and lire nltached to the shaq> interosseous Iwnlerj o( 
both buiH's. It is ]iierce<l above by tlie anterior tibial vcasels, ami 
near ila lower ]iart by the anterior ]>er((neal vessels. 

Below the iiiteroiMjeous meiiibnine is the inferior int-trntteout \ 
Intnl. whiib consists of very short fil)re8 passing between 
triiingulnr rough inijiressions on tho luljacent surfaces of the tib 
and fibula, inunediatcly above their inferior articulation. 

The Inferior tibio-fibuhir articulation (Fig. 102) is a simple 
arthrfHlial joint, continuous with the ankle-joint. It has antenat— 
and posterior ligauienta between the two bones, resembling 
alMve, and in adilition, placed below the posterior and disli 
from it ; a transverne (or inferior) ligament which reaches 
the external malleolus to the posterior surface and malleolus 
tbe tibia ; and the interomeout lijiatiient just described. A fold 
synovial membrane is often prolonjied for a very short diltauOl 
between the two bones from tlie ankle-joint. 



Ankle-Joint asd Abticulations ok the Foot. 

The ankle-joint is almost a pure ginnl.vmiis, moving 15* (fi 
the positioH of station), iji the direction of dorsal Hexion, and 45' i 
that of phmtuT flexion. It has in front from within outwards I 
tendons of the tibialis anticus and extensor proprius hallucis, 
anterior tibial vessels and nerve, the extensor longtis dij^'itoruni, i 
the peroneus tcrtius. Fixing these structures in place is 
anterior annular lij^anienl, and more superficially lies the muM'ull 
cutaneous iien'e breaking up into it.s internal and external branch 
it'hini, arranged from within outwards are the tendons of 
tibialis posticus and flexor digtturum longus, the ]>osterior tib 
vessels ami nerve (or it may be the plantar vessels and nerves), I 
flexor longus hallucis, and behind the external malleolus, the leudd 
of the j)eroneu8 longus and breris (Fig. 103). The ankle-joint 1 
anterior, jwisterior, and two lateral ligamcnt.«. 

The Anterior Ijigament is a broad thin membrane whioli I 
seldom seen entire. It i.s attached to the lower margin of 
tibia, and to the superior surface of the astragalus, close to iti hetilt 
and joins the latend Hgfimcnt on each side. 

The Poaterior Ligament is not described by many authd 
and it is seldom rejirest-nted by more than a few tibi'es streti 
over the sjTiovial membnuie lietweeii the back of the tibia and I 
astragalus. 

The Internal Lateral Ligament (Fig. 104, i, 2, 3. 4)^ 




UGAICKKTS OF THS TABSUS. 

ia it whnv it {«M(« uitiier th« huad of the wtngalnt mi] 
fbrces th« iuffrior adcan<>oMrapkui«l lixanieut. It ia •ttachml to th 
tmhtmiiXy ot Ibe «ca|ihoiil bone and tb« wljnctmt iiit«Tiuil euDoiform '' 
bone, and giro tlijm oIm to all the otiicr \wnt» at the tontu, witlt 





tlir cxee|ilJoa of the atitof^luii, and to tlii* nvcond, tliinl, and tbUTtli 
1 r«l txbius. Tbece mtut be tvmuved to nee the true Ugaiueiita 
■ •; .»-c joint*. 

Ugamenta of the Tarsua. — On the dfimU wiioet of the 
remaining tarxal \mne» will 1hi found a niimbrr of nhnrt luuuU of 
fibres, which ]iMi>a bi-twcfii ivIjikciMit IxincA niid have n'cnivcd nnmri 



Far- 106.— UguDcati of tlie outrr dde of Um uikl* nod foot (ftvm Sa]>p*y). 
tibio-Abular 



1. Aatcrior infrrior 

Uff.tinfiil. 

2. ill m1u» nf rxlomiil 

I rut of anklr. 

3. Ao"n." ' cif pxtcniol 

Ut<-M> ' ankle. 

4. Extcmn! ' • aitTagalnr 

Ucuncnl. 

5. Ext«nMl calauieo>«ca|ilioid ligm- 

ment. 
A. JnUmMMoat catouitOHWtritalar 

liptRtrnt. 
7. Saperior ••tnpilo-irnphoid lig«- 

mctxl. 
K Eitctnol c*le«net.-cuboid lipi- 

rnent. 
9. J*nni>l lisimirtit belwwn acniilmiil 

u- ' .1 ntDi'ifurm. 

]0. III! '-o-ciilxiiil liK*iii<'iit. 



II. llnrul lii^mciit lH>twi'i>n cxtvni*! 
tiii'l nii.lillo I iiiu'ifonu. 



Vi. 


I)n = 


it Wtwrmi >ni(ibiiid 


Vi. 


I).. 


1 botwrni cxtrrnal 
mil Uiinl inrta- 


14. 


D. 


iwwn i-uliold 


16. 


v.. 


:.. l»ccn middlo 
jid Mwond Diotk- 



10. Doi'ul lijjanicnt hrtwpen culioid 

mill thinl And fnitrth nu<lii- 

UnHla. 
17, 18, IV, W. Itoml lixBincnU be- 

twri-ii b«u>« iif maUUrul 

Iwuc*. 



214 THE CALOANEO-ASTBAOAJLAR ABT1C0LATIOK. 

and intfrotttoiu b'gainents. The rjcienml (Fig. 105, 4) is > sboit 1 
passing obliquely backwards from the side of the ostnignltu bell 
the fibular facet to the adjacent part of the outer surface of the 
calcis. The posterior (Fig. 102, 12) is placed betwecu tliL- pieteB 
of the two bones, cloi«e to the groove in the aslragBiua tliruu 
Iwhich the teinlon of tlie flexor longus hallncis passes. The intr\ 
oui (Fig. 103, 5) ligiuuent will l)e seen when the joint is opene 
It is a strong thick band, passing from the groove between 

Fi?. IW. 



£^ 



J 



two inferior articular surfaces of the Bstragaliis, to the correspondii 
groove between the two articular surfaces on the superior aspect 1 
the cnlcancuui, and divides the sub-astnigalar synovial cavity into tl 
parts, an anterior cniitiiiuriiiK with the astriigalo-scaphoid joint, ; 
II posterior directly beiieuth the ankle-joint. The doulde artici 
lion, to which the natue talH-cakiineo-ncayhoid joint may Ije giva 
is the seat of nearly the whole of the lateral motion (ulxluution < 
adduction) of the foot (Fig. 107). 

The Inidon of tlie tibialia posticus may now be seen crossing > 
deltoid ligament, and will lie found to have a fiuro-cartilage develo 



Fig. KM.— Ligamentf of the iuner tide of the ankle and foot (from Sappey), 



1, 2, 3, 4. Differor.t imrts of internal 
Intoral UguniMit of nnklr. 

<5, 6. Inferior ealfjinco-Hraphoid ligii- 
nit'Ut, joined liy iiiiUrior libres 
of intcnial latornl hKiiiiiuMl. 

7. Internal Upiment lietweon inter- 
nal cuneiform and lirst mcta- 
UrtiiL 



8. Liiraiui'iit between 6capboid 

internal cuneiform. 

9. Inferior ligament lietween into 

uul cuneiform and first md 
tarsal. 

10. Inferior U^nunent of first mcta* 
Ureo-pbalungeal Joint. 



LIGAMENTS OF THE TARSUS. 



216 



it paiiece muter the head of the luttrngnlus and rein- 
|tl»e inferior ca]cnne<j-*cflplioid lij,'juneiit. It is Attucbcd to thftj 
ily of itie Bcaphoid Ixme and the ailjacent internal ciinmforral 
Vme, Kud gives alipii iiloo to all the other bones of the tiimu, with 

Fis. lOS. 




the rsception of the ostnigalns, and to the second, thtnl, and fourth 

'T-wI bond. These must bo removed to nee the true ligatumtn 

jciinttL 

Xjigaments of the Tarsua. — On the dartal oapvct of thi- 

rvninining tarsal lioiieu will I* found a nuinlH.-r of short bonds of 

filrres, which pass between adjacent bone* and bav« rpevived names 



Ig. 106.— ligament* of the outer «id« 

.interior iiifrrior tibio-ObuUr 

liEnnirnt. 
Mill" '' mIu» of rxtrmal 

1 lit of itiikli'. 

Aji'' lilii* of fxtomal 

UiUnii Uijuiiicnt of ankle. 
External ralrHnL*o • ndtnigutur 

Ugmmmt. 
ExtmuU calr&UFo-a<''jiphaid ligra- 

mcnt. 
Inleroaaeoua calcaneo-iutnigiitar 

Uguamt. 
P; Saprrior aatnigala-iraphoid lign- 

mrnt. 
Elt<Ttii>l <iil«inei>-inil><iid lign- 

9. Doi i between ncaplinid 

ui^ I ''unciform. 

10. Istimwl oalranixv-eiiboid lipinirnt. 



of tbu nnkU and foot (from Satipoy). 
II. Di.r- " I'n otti'ninl 

■!■■ Mil. 

\'2. Doi~.. M..i.u.. <.i u.. I n 1 1 n Kn|ihiiid 

Utill I'llllliill. 

13, Domal li)rnini<iit between eitemal 

cunrifui'ui luul tliiril mela- 
tnraul. 

14. Dorxil liKnment Itetween cuboid 

nml lllth iiirtnliinuil. 

16. Doi-Mil li^fiiinent In-tween middle 

I'umifunu und ircoiid oictM- 
liii>al. 
Ifl. I)or«iil liicnment between cuboid 
niid third and foiirth m«tn- 

tlLTtllLlj*. 

17, 18, It), JO. Donal liganienU be- 

tween bates uf nieUitaml 
iHinc*. 



I 



216 



MOAM£JJTS OF THE TAUSUS. 



as ligaments nccordiiigly : on the jtlautar tu-pect lliere urf timihrl 

but Blroiigcr ligaments, tliree of -which are worthy of sjwtul 

notice, vix., the lung and ehort calcmieo-cuboid Ijr^iunents, and tiK 

c«k'aiieo-»ca]ihoid ligamtntf. I 



Fig. 106. 




Another set of ligiunent', 
caIIoI inteTO»»tirii», coDOmt 
the O[iposed lateral siirfac*- 
of the bones where the ar- 
ticular facets arc? deficient 
(Figs. 107, 109) and will he 
seen later. 

The Long Calcaneo- 
cuboid liigament I i'ii'. 
10(>, 9) — /*;/*l7>l/^J/l/Tr^ Itjviiuru 
}>lanloe — is a broad lij^unnrnl 
whicli has been idready *«cn 
in the disaeoticju of the folc 
of the forit. It is exten- 
sively attached to the uiider 
surface of the o» calcis ui 
front of the luberoeities, and 
passes forwai-d to be fixed to 
tlie posterior margin of the 
peroneal groove in tin.- cuboid 
bone, some of the fibres pao- 
ing over the temlon of the 
peroneus longus (for which 
they form a sheath), to be- 



Fig. 106.— LigrunenUi of Uie 

1. Foiiil of ttttmlimeut of tendo- 
Achillis. 

2. Iut«nuil innllcniu*. 

3. I'oateiior tubpi^fity of o« calcis. 

4. FotU'rior part (if uiitragaluB. 

5. Eztcmnl tubercle nnundrrauriace 

of OK ealcii. 

6. Fontvriiir culcaueu - actragalar 

Ugaiucnt. 

7. InternnJ tubercle on under »urface 

of o* calciE. 
8 end 12. Intrxual lateral ligament 

of ankle. 
9, Long pluiitar lignnient. 
10. Uioorc en eustentnculum ttili for 

flexor longue pollicii. 
11 Short plantiu- ligument. 



cule of tile foot (from Saiipey). 

13 and 'J3. Toodon of peroneu< lou- 

gui. 
14, Iiiturior calcaneo-ioaplioid li(a- 

incnt. 
lo. Sheath of peroneua longus. 
16. Slioit plantar ligament. 
17- I'lnntar ligiinicnt between fourlli 

and fifth nietatflrsdls. 

18. Tubercle of xiuphoid. 

19. Plantar lit'nnunt bulween third 

and faurtb nieliUoi-aalB. 

20. Plantar ligament between M'opboil 

and internal uuneifomi, 

21. Fifth nictutiirsal. 

22. Internal cuneiform bone. 
24. Firat metatarsal bone. 
26, Sheaxb o( ^etoncMs Voncus, 




LIGAMENTS OF THK METATARSUS. 217 

come attached to the bases of the second, third, and fourth 
metatarsal bones. 

The Short Caloaneo-Cuboid Ijlgament (Fig. 106, ii, i6), 
more deeply placed, lies to the inner side and under cover of the 
long ligament. It reaches from the anterior tulwi'ulc on the under 
surface of the greater process of the os c^ilcis, a little behind the 
calcaneo-cultoid articulation, to the under surface of the cuboid 
behind the ridge. 

The Inftrior Calcaneo-aoaphold Iiigament (Fig. 100, 14) is 
a broad yellow elastic ligament, stretching between the lesser process 
of the calcaueum (stutentaculum tali) and the jiusterior border of the 
inferior surface of the scaphoid bone, blending internally with a seg- 
ment of the internal lateral ligament of the aiikk-joiiit. It i>eT- 
forms the important function of su]ii>ortiiig the key8t<me of tlic 
longitudinal arch of the foot, the head of the astragalus, which 
testa upon it between the anterior calcancan and the scaphoid facets ; 
and in this is materially assisted by the tenduiiH of the tibialis 
posticus and of the long flexors of the great and IcHser toes, which 
pass immediately beneath it. The upper surface of the ligament is 
lined with the synovial membrane of the tulo-valcaneo-scaphoid 
articulation. 

The intetvtteoiu ligaments will be seen when the joints are 
opened. 

The Metatarsal Bonea (Fig. 105, 17) are connected with the 
tarsus by strong dorsal, plantar, and interosxeuuif ligaments. 

The dortal ligaments run to each metatarsi bone from the 
tarsal bone with which it articulates; but the necond metatarsid, 
in addition to its ligament from the middle cuueifonu, ho.'* extra 
slips from the internal and external cuneiform bones, between 
'which its base is wedged. 

The plantar ligaments are less regular, and are united with the 
slips from the calcaneo-cuboid ligament. 

The interotteoHi ligaments arc; short strtmg bands, and var}' 
slightly in different subjects. There is always one between the 
internal cuneiform and the second metatarsal bone ; a second may 
exist between the external cuneiform and the minie metatarsal bone ; 
and a tliird between tlic external cuneiform and the fourth meta- 
tanal bone (Fig. 107). 

TVantterte dortal, plantar, and interosseous ligaments connect the 
bases of the metatarsal bones. 

The Byno'vlal Membranes (Fig. 107) of the foot, including the 
ankle-joint, are seven in number, and will be seen by opeuii\g l\itt 
tereial joints in ruccemon. 



218 



Ur.AMESn or THE Ti 




MT pert «t ibt 
the oppiaal 



iij\'j- 




' {jurt uf liie ume aiticulittion and lines the inforiur ualcaneo- 
Hiil|ili'iiil niid the (iU|M.'rior ii»trngalo-«caplioid liganienU fill). 

Tilt •lr'iiif{ lulerooMfoiu lir/ament coimecting the under surface of 
tliti MlmK»lua and ttur u|>per iiurfuce of the 0$ cjilci:) will now be 
iiCi.'upyinK thr. de<-p groove between the two articulationi in 
Imnti. Two inlrrnueoiu ligaments, the intenml (altaiieihciihti'ul 
thf rjiitnutl MUanro-Muplimil, will also he seen, when the aslra- 
({uliii in di»pliu-ci|, pait»ing fruui the upper V>n.ler uf the greater 



Hcn I 



mil 



Pi(. 107. — Brotlon to ahow the aevcn aynavMl membrene* of the foot (from 
WIUoii). Till] ri'Hoctian of Uio membrane over the HrticuUr ckrtilogct to 
rrT<mi«>iM, 

8, Internal cuneiform. 



t. Tllilu. 

*i. A«tiii)rritil«. 

II, CMli'iini'iiiii, 

4. Hi'n|>hiild. 

6. Cukiiiil. 

d. Kxteniiil cuneifi>rin. 

7. Miilillu <'un<'lfurni. 



9. Firat mctataraal. 
10. Second metataraaL 
It. Third nu'taturaal. 

12. Fourth mcIiitnrwU. 

13. Fifth metutanuil. 



SYNOVIAL IfEMBRANES HK K< loT 



219 



ymuu m of ihe on cjUci* u> the cuboid aud acupUuia Lxjiira nay 

'■■ Hj-nuvial iiHMubrane (iv) l«longs to thi' uilrancoinilMjul 
I. uzkI wbvti it in ii{>).-iio<l, tliK |<t:>'iiliiir manner in ulikh 
the two Ixtnoi ii« lockol loj^'etlier will be wen. 

The 5th aynoviiil meuilmuie (v) 1» common to thu »c»|iho- 
eancalann, inter-cuncifbrm, and cuba-cuueifunn urticuUtiotui, and U> 




tlw joiBti iMtVND tlie middle and t:xt«nial cmueitona und the 
oouopufuUug metatarM] l-uneii (vn), and iji aliiu prolont;^! into the 
•rticulatiun* Uttween the aecuud, third, and fourth mctatArial 
bosws (u). 

Inttwomtma ligament* will lie foun<l between the (caphoid and 
CtUioid bone* ; between the internal und middle cuneiform tpontw ; 
beCWMB Uie middle and external cuneiform bones; and lietwf<ea. 
Uk «xt«ii»l ciuivifurm and culxiid bonen. 



Fif. UM.— Luofitodinal M«tiiHi oTfuot (after Birnuiw). 

t. yinorVmsaalnllari*. 9. Adductor minimi digiti. 

1. Fl«>«r torria haHnH«, 10. (3> ealrU. 

3. tin^rirali*. II. EstniHr pi«|wha balladiL 

4. ykxor iRvrb difit«rum. 12. Intaaal enaaUtonB. 
<k latoraal plantar nerra. 13. ScaphaU. 

(l Fkaar MonDoaia dicHoram. M. Aitra^ilui. 

7. Jill— rim \S. I'oati-riot tibial tcbwU and I 

K Eztarvl |dantar *«*aisb am! It). THld»-AckUlia. 



220 



SYNOVIAL MEMBRANES OF FOOT. 



The eth synovial membrane (vin) i» connected with the 
butweuii tilt' cuboid bone and the bases of the fourth aiiJ &fUi 
nietutjinsol bones, and is prolongwl into the articulation ImjIwuvu ibc 
latter. 

Tlie 7th is a separate synovial muinbrane (vi) for the jwnt 
between the first mvtatnrsal lx>ne and the internal cuneifum 
bone. 

The mechanism of the arch of the foot may now be sliidied, mil 

Tig. 109. 
» igc7 16 Ki M 13 utir 11 




till' value of the poiverful teiuloiiH, nuwcles, fasciaa, und li]KTUUcnt» 
beiientli the nole as chords lUiJ tics to coMiii'ct the elements of ih' 
ftrcli, will be rwidilv npprecinted. It i« the insufficiency of ibes* 
niusculur mid ligunientous structures thnt peniiits the .'(inking '» 
the iistragalnr key -stone which coiiMitiiles the essence of " flat fi>ot. 
The 8o-<ttlk'd "trnnsvei'se iiivh " of the foot is not an arch in ih* 
aame sense ns the true or lon^itudijial arch. 



Tig. 1U9. — Vcrlical icction tlimueh the cuneiform uid cuboid 1 
(after lleiile]. 



1. Abductor minimi digiti. 

2. ExtonmlpluDtRr rptM'lis iindncrrc. 

3. Tcnduii dl p(.'roiH'un tongue. 

4. Flexor bifvi* (tigitoruiii. 
0. Flejior lotigui ctigitonuu. 
0. I'lnntar funciu. 

7. KlfXnr I<tu,}^i« hnlluoi*. 

8. lU. AbdurturhuUui'ia. 

9. Iutom.ll plantar vi-stelsindnerre. 
11. Penmeu* tertiui. 



12. Cuboid. 

li. DorMiI aponeuroiit. 

\'y. Exti'DMr brevis digitorum. 

14. External cuneiform. 
Ifi. Middle cumifonn. 

16. Uumlis [Hilis rcsacla and n« 
17 Extrntor Inn^s hailuci*. 
18. Intcrniil cunt'ifunu. 

15. Tibinlii uitious. 



SUROEKY OK TUK FOUT. 



221 



he terni fni?i«rirr«i hiTfil joint i« u surjficul luinnuiuer fur the 
liiK" nf articulations fici>anitin^' tlie itritruj^al 118 and caliiinciim Croin thu 
cuIhiiiI and DCAphoitl. The luitm^nlni' nml calniiic^aii juirti>>iH of this J 
" joint " lire iiuito ilLstiiict frtun rarh other, hoth aniUnmiiiilly and' 
phy.iioUigiottUy. 

The morrmenU uf iLe Ijirwil and tarso-niulatunuil juinta ore for the 

most i»iTt rt-^Lrictcd to n »li}{ht ){li(liiit{ of tlie surfuces of ench bunt: 

over tlic t>piio8fd aurfocca of it< ncighbourti, but in the uiticula- 

tion <if thu OMlra^nliiK witli the cjiluanviim and ncapbuid (t«Iu- 

• ij-wajiiiiiiil joint) there ia a vi-ry ronniiler.vlilc nin^x! of 

. aroiinil un iilmoxt vurtiin) nxiit imwin^ tlir<>ii);li ihi- middlo irf 

.■roB*(.-oii» li^uielit. It if hi'i'C that iii-ftllv iht' whidu i>f lliu 

■itm' and ' tiitilucliun ' of I he aiil«Tlor purl of thu foot tiikt-s 

pWv, tuiil it niny bo noted tliat tlit; ankle-joint tiikvs uu jHirt in 

ititsBu Utenil niKtionx, uvi-n dnrinj^' phintjir lU'xiun. Strictly 

sptuiking, thi' niiivcnicnt in one of lulriiiction with idcvation of 

the jiuiM border of ilje foot, and the abduction in nwrely riv<titutiou 

to the original puailiou. 

The foot in addiLcUd chiefly by tliti tibluliv itiitktu, Mbialia 
jMMticns, and tiexor lunKUs digitorutn, luui abducted by the peronei. 

Surgery. — The oliajM" of the ttrticnljition« xhoiild be luiiticularly 
noticed with refeituce to the i>evcnil an>|)UtationA oImiUI tile foot. Al 
the unkle the Hxttiif^ol nn is locked between the proj^-cting niidliToli, 
and it i' only by clividin^ the lateral Ii;;anients, by the nide of tho 
aHli-u^aliii) iind ont«ide the joint altogether, ihut the bune^ can bn 
>«psrat4-d, a» in Synie'i> or Pir>>Koir'K naipututions. 

The ttstni}.'ul<>-iic«plioid »iid cnlcaiuwj-culKiid nrtienlntioUH will Iw 

rfcn to be uearlv in the winie line, and are easily oiH-ncd in Ch"|i«rt'» 

lition. Till? ^'uide» lor thiw oiwratinn arc a point ininiiiliately 

! the tuWrcle of the !4:jiphoid bone on the inner side, and a 

iiiidwny lietweenthe external inalleohH tiiid the tulierule at the 

t the fifth laettttuiiHil bone .m the outer wide. If, in ^HTfoniiiii),' 

M-nttion, the urlicuhuion in front of the scaphoid should bwj 

I by mistake, the ojieiatfir would at once see the thrive orticilla 

.,.^cs lor the cuneiform bouci instead of the single spheroid 

face of the oatrngiUiis. 

'The <.)(ita-atiou of dihiirticulutiuK tho metatantiut from the tarsutf^ 

Iny'n or Lisfi-ancV amputation) it> rendered verydilMcult \<v the fact 

At the haw of the necond nielntni-MiI bone i» tirnily wed;;ed bftweeii 

the inleniiil and external cuneiform l"ines, projcctinj^ faither into 

the tarnuii than the other bone-s, and being al.'*o attached to thu 

internal cuneiform liya strong inten)«»eou.i ligament. In amputatiiij; 

at thi" jioinl therefiiie, after opening the articulalinn of the lii>t 

td tltn-e outer nirtatjirsal bones*, it in neceiwiry to lliru'tl llie point 

" the knife iietirccu the iultinial luuejform uud second luclatoiraiii 



222 



METATARSO-PHALAJIGEAL AKT1CULA.TIOXS. 



bones to divide this ligament, or there will be danger of »L ^^ 
away tlie interiiiil ciineirdi-m Ixme. The iirticulations ate plao 
obliijuc'lv, tliat (if the lifth being jMwterior to that uf the fin 
nietataTHat bone, the base* uf these two hones fomiinjj the guid 
to the surgeon. 

The articulations between the- metatarsal Ijones and the phaTatig 
and between the phalanges themselves, are similar to those in 
liand. Tliey are, however, on a smaller scale, and therefore uo 
diHicult of dissection, except in the case of the great toe whe 
the articular elements are well defined. Phj^iDlog:ican_v 
great toe differs from the thumb in its adaptation to gust 
the greater jiart of the weight of the body in walking, and 
its iucajiability of opposition to the other toes. 

A shortening of the inferior portions of the lateral ligament* 
the metalarso-phalangeal joint in the great toe is present in 
deformity known a.s " hallux flexus," and a siniihir condition exiil 
in the iiiter-phalangeal joints of the smaller toes in thi' 
complaint called •' hajuuier toe." C 



/ 



. AUu.^' 



226 



ARTERIES OF LOWER EXTHESnTr. 



T.VBLE v.— THE ARTEBIES OF THE LOWER EXTREMITT. 

f Oxmnon Femoral Artery. Bifurcntea into niperficuil nnd de«p femornU. 

1. Superficial L-pignstric. 

2. Su[><rticial circuiufliix ilinc. 

3. Supcrticiul exlornnl pudic. 

4. Deep extemul pudic. 
Deep Femoral (profuuda). 

1. External Ciroumnex. Ascending, traiuTene, md descendius bnaetel 

2. lutcruol Cirt'uinflex. Muscular, articuliir, and two terminal DimofihM* ' 

3. Porforatinp. Four, im-ludins termiutl branch. 
Superjicial Femoral. Bet'Oinea popliteal. 

1. Muwulur. 

2. Anastomotic. Superficial nnd deep btvnchea. 
Popliteal. IlifiiroAtes into anterior uud posterior tibial. 

i. Superior muscular to hamstrings, &c. 

2. Fire articular. Superior and inferior external, superior and inAriori 

tcninl, and uxygos. 

3. Inferior muscular or sural to calf muscle*. 
Anteriur Tibial. 

At back of lea [ J" ?«'<"?<"■ tibial recurrent. 

•''12. Supenor hbular. 

1. Anterior tibial recurrent. 

In front of ley 2. Muscular. 

3. Two malleolar, internal and extemul. 
On foot 1. Tarsal, internal and exleniiil. 

(Dorsalis pe- 2. Metatarsal. Interosseous branches to three outer s 
dis artery) 3, Dorsalis hallucis yirat ilora-il iuteraaseoos) . 

4. Commuuicntin;; (first plnnlur dig^itnl) to plantar oich. 
Potttrior Tibial. Bifurcates into external and internal pluntur. 

IMuscuhir. Medullary to tibula. 
Anterior peroneal. 
I'lMterior peroneal or external r«lc«neaL 
2. Medullary to tibiji. 
Muscular. 

Communicating to peroneal, 
lutemiil calcaneal. 
'emal FUnitar. Muscular. 
Extertial Flaiitnr. Forma plantar arch- 

1. Caloanral. Internid and recurrent branches. 

2. Muscular. 

3. Posterior perforating. 
\<k. Digital. 

Anastomotic. 

Gluteal artery. Super6oial and deep divisions. 



i Internal 
niac .... 



Sciiitie artery. Inferior gluteal, 
ischiadici, anastomotic. 



coccygeal, comes nerrf 



KKRVES OF I/)WER EXTREMITY. 



227 



TAMLE VI.— NKUVES OF THE LOWKR E.XTUEMITT. 

Putsnmtn to mitj-r tiilo of liuttoclc. 

inA, 3nl, and 4th lumliar, ond branch from 12th doml. 
, iliac tirtin<:li , , | 



12th donitl and Itt lumbar i 



iio-rrurol. lit and 2uil lumbar j Cutaneou* to thigh. 

, — 2liil iitid Itnl Ittrntxir ..•.. ' 

Balnr, '.:ti(J, M'i, oud l! I 
( A- q,. 

^^r I aubwrtonui to ptcxui. 

^.mwf .n-uwn . . . . j j, ^ oxtoniiM «nd adduotor magnui. 

Ut, 2nil, ii:ir. 

(. ulniHiiuo lu lluuli- middip and intcmnl. 
Mii«<-ul:ir til ALirtitriiit (mitUllo rutanooiii). 



Dap diritioH 



' teiatle I 

fr *. . 
Mu 

\ 
I 

t 

.1. 



Auttritr tiiinl 



Tntfmal popliteitl. 



Aiii 

.M 

t 



jI'IJ I<> IcII 



J\i$Urior litiai 



M'i*r(il:i' " -iKl iTiircu«, 

I l..'ii^- < i; kniii, Irg, and ftiot). 

' uuii 4th •aeiiil, uml lititntli from il\\ lumbar, 
iiitl miniinim, imil trtiMir va^ltiin fitmnrli. 
: '- ' ■ -'- • iM miiximua. 
■'f. 

I , givp* nrlieular ntrv* to hip. 
i.ltiuuul) to perinn'uin, 



popliteal, 
rid adiluctor marnua. 
. ul>>-^ utuuixuA 4iid Huti'rior tihijil, 
!. iiifcriur rxtrrnal, and rroiirront. 

l'(f. 

'it'i. 

[0 peronei longiii and brovla, 
Akin of ilormtni of fiKii, 
UuBinilnr t>i tibiiili* uiitK'n, extennor louguidieitorum, pxtra> 
ftiir luiiK*"* li»Mti('i'i pi'niiiKiia ltfrtiuii,«stt5iiiHir brvvia dlgi* 
tnnim, iind lit jind 2nd dorsal intrruuei. 
Arti''«li<r i'< knii-, imkU', und titriiu. 
Cii- ^,„l. 

■ riiir tibial at lower bordfr of puplitoui. 
I-. '- -, - - iU-niiil. infrrior iiitt'niul. and uxygok 
iifiiiiuN yl\, \\\ni\\Mr\i, pnpliti'uii and Mnlmta, 
'I'i, j'iiniujt ronununiiinnt pvrunci tu form ahort mphnnoutJ 

Mui«-tilnr t'> a'dt'iis, fli'tor longtu digitornm, flexor Inngun haU j 

luoi>, and tibialia {joatuua. 
Intvmul ailcaniuU. 

Muaeular to abduetor and flexor brerici 
> " " ' ii-ria digitorum, and IstI 



Inttmiil plantar 



Eileiiul 



" I Cutaneous and digital. 



I plantar, 
u»Acs ot *a\*. 

1 a 



226 



.BTERIKS OF ^^O^-^^ 



EXTBEiO'T"*'- 









,„ foot U McUta"t ,l>?cU (fir»l '^"'*^ iSl^l) W pl»n'* 



. r.i..«'. mfU^'Kury to fibula. f 

Ptt,«i-i<.r Tift""- , Muscular. MJ^^„, , „.,,,ttiieal. ■ 




re»teraaU*l««»"^- 



.r«.»e..l\t:^--:?^:l-.e.en^^ 
., Medulluryt^'^^""- 

2. Musk")*'- rfomting 



From l"^" 
niB'' 



iirtor»"**" 

A.:. , ,,,, Super6c«l»nd^«<'fSeal; 



t^-t^: 




NERVK3 OF IX)WER EXTREMITY. 227 

TABLE VI.— NERVES OF THE LOWER EXTREMITT. 

Jktrmil. Cutaneous to outer tide of buttock. 

tmr Flexut. Ut, 2nd, 3rd, and 4th lumbar, and branch horn 12th doraal. 

c^t*s:5:^i'!^.'"°r!'..::l»2th.wi.nduti^^^^^ 

L Crural Bratifh of gcnilo-frural. Int and 2nd lumbar / Cutaneous to thigh. 

L £xtemal Culaneout. 2nd and 3rd lumbiir ' 

i. Obturator. 2od, 3rd, and 4th lumbar. 

iArlit'ular to hip. 
Cotaneous to thigh — Dccusinnnlly. 
DetB diritiou \ Articular to knee. 

^ ' ••••\ Muscular to obturator extcnius and adductor magnus. 

S. .Anttrier rrurnl. li>t, 2nd, 3nl, and 4th lumbar. 

jcu«^>«..'./ ^.v.-....„i Cutaneous to thigh— middle and inlenial. 
auperjtciai airuten^ Musculnr to sartorius (mi<l<llo .utaneou-). 

f Muscular to pectincu", rectus, viisti, anil crureus. 
.Vrticuliir tu nip and knee from the above. 
Long saphenous (inteniul i:utan(*ous to knee, leg, and foot). 
mtplejcut. oth lumbar, 1st, 2nd, 3nl, and 4th sacnil, and bninch from 4th lumbar. 
E. Suprrior glntral, tn glutei meilius and minimus, and tcnsi>r raitinic femuris. 

2. Inftrior gluteal (occurs from small sciaticj to gluteus maximus. 

3. JfuMCular to obturator intemus and gemellus superior. 

tt. Jtutrular to <|uadratus femoris and gemellus inferior, gives artieular ner«'o to hip. 

4 Internal cutaneous (infi'riar pudendal} to perimi'um. 

B. Letter teiatie I Recurrent cutaneous to buttock. 

( Ueiwvnding cutiincnus to hack of thigh and le;. 

B. Gnattr teintir. Ends by bifurcation into cxti-miil and internal poplili-ul. 

a. Muteular to bice|m, semitendinosu'i, Mmiimenibniiiosus, ami a<lcluctiir magnus. 

fi. External popliltiil ; bifurcates into muwulo-i-utaneous and anterior tibial. 

Articular to kniv. Su]H-rior cxtemiil, inferior external, and recurrent. 

Cutaneous to outer side of knee and leg. 

Communieans peronei. 

MwfeHlo-CHtatuoHt to peronei longus an<l brevis. 

skin of dorsum of foot. 

■ Muscular to tiliialis anticux, e\lensiir longus digitcrum,exli>ii - 

I sor longus halluci*, iieroneuH terlius, extenaor brevis digi- 

Anterior tibial i torum, and lot and jnd dorxal interussei. 

I .Vrticular to knee, ankle, and tar^u•. 

\ Cuioniiius to f(K)t. 

y. Intfmal popliteal. Becomes posterior tibial at lower border of ]iiiplilcHs. 

Articular to knee. .Superior inti-nial, inferior intcrnnl, ami azygos. 

Huiicular to gastrocnemius (2), plantaris, poplittus ami soleus. 

Conimunioant poplitei, joining communicant pcrimii to fonri sliort saphenous 

nCTTO. 

.'Huseular to soleus, flexor longus digitorum, flexor longus hal- 

lucis, and tibialis postiitis. 

Internal calcaneal. 

I Muscular to abduitor and flexor breris 

I hiilluiis, flexor brevis digitorum, and 1st 

Patterior tHinl t_*™„i _i .->.. and 2nd lunibricals. 
Internal plantar fu,,,,,,.,,,,, pi,,,,,,,,.. 

Digital to 3J inner toes. 
('ommuniratiiiK to I'xti'rnal plantar. 
I ExteniaJ plantar / Must^ular to all other muscVe» ol «.,Ve. 
'^ ( C utaneouii and digital. 

Q 2 



kT^ 



PART III. 



DISSECTION OF THE ABDOMEN. 

[The ShtdeiU it requettfd to read tht ' IntroduHion' before tommtm 
the diuectioti, wiUtt he hat dont to on a prtvioiui occation.] 

Surgery. — Before the gnViiect is tied up for the dissfotion nf L 
penniciiiu, the rtudent should practise tlic openition i'>f introdncn 
the cntlieter. 

In the cAHe of the Male Subject the operator should stand i 
the left eide of the IhhIv, and )iaviiif{ oiled u jK'rfectly smooth *_ 
clean sUiff ur wMind, should urtL^p the end id the penis with ihi 
left huiid, and diiiw it upwanls so as to stretch the uri'thiii «liilrt 
intrcKlncint; the instrument. The sound is to Ije held li^'litly in th< 
right hand, and is to be passed at lirat alon-; lljc fold <.if the J,'^.in, 
hut when it liaB entered the urethra for a few im-hes it i^ tu \r 
lirou^ht pandlel to the median line of the body and pressed 
onwards, Keeping its point constantly against the U])per wall r.f ilic 
urethra. The intiiKluction of an in.struniunt is more dithcult on tii« 
dead than on the livinj,' Ixuly, owiufj to the want of the marna* 
secretion of llie urethra and the relaxed condition i>f the canul ; an<i 
it is aii visa hie therefore to withdraw tlie instrument and oil it aimh 
if any ohstruction should occur. 

If an olislruction he encountered, the left hand should }«■ ' '" 
upfm the i>eriniDuni at the jxjint to which the slatf has reaclh 
may be made to grasp the urethra and guide the instrument ui IM 
rijiht course. 

When the staff has passed tlie bulb, the handle is to lie d. pr ; ■' 
lietween the thighs, and the point will probably enter the 1 . 
If it is found im|)o83ible to depress the handle, the student < 
certain that he is stopped by the triangular ligament, ami 
be ver)" gentle in his manijiulations, or he will very probul I, j.. 
fonile the bulb. By a series of cautious efforts, aideil by the Uft 
hand on the pcrinseuni, the staff may at last be i>assed, but ifj 
organic i.U-icture should exist, it will be necessary to lue n i 
instrument. 

When the handle of the instrument can be depressed between Ihf 
tliigh.s, the student may jxidge of its \m\vug fcuVemA. tW VtUddet " 




THE PERINJiUM. 22U 

the ieiuliiiC!>.s with which it pniwed, and by the ease with which the 
end of the stuff ain Iw n)tut(Al in thu l>]iuldiT. lu all l■a^<t.■><, huwever, 
it i» aJviiUkltle for the .ntiuleiit to iuti-odiutu hu left fiire-tinKi-r into 
the rectum, iu order to iiM;ertain that the instrument U not in a falsu 
pasaaue, und fiL-io in order to appreciate the thickneKx of the coiitx of 
the bliulder, the size of the prostate, and the coui'xe the catheter 
wonld take on the living IkxIv. 

In the Female Subject it will lie adviMlile to examine the 
position ot the urethra Ly Bepamting the lahia, liefort! atteni}>tinj{ 
to introduce an elastic catheter. It will \m wm that the oritice 
of the urethi-k is 8e(Kirat«Kl from the ulitoria hy the xpace known on 
the vestibule, and that it i.s close above the entrance to the vagina. 
To poKH the catheter, the Htuilent should stiuid on the riKht side 
of tne subject, and having ])a.«set.l the left fore-fniger lietween the 
thighs and labia, should iiktce it at the anterior edge of the oritice 
of the vagina ; a flexible catheter lieing then ]>iu<.sed along the 
fore-tingcr can lie slightly raised so as to enter the urctlini, ami 
will Ik- felt in it:) luutsiige through that canal by the finger at the 
orifice of the vagina. It will be well to pnictise the operation 
oiice or twire with the jmrts exiMised to view, and then to repeat 
it with a cloth thrown over the pubes, as would be done in actiud 
practice. 

The Perineum. 

[The perinu;um is now to be fully exjiosul by bringing the 
bDttoc-k« of the subject to the edge of this table, where they ttiv to 
le raiseil up<inablock. The thighs are then to be flexed u|Min the 
mbdoineii, with the legs bent ; and the Ijody is to be s<>cnred ujjon 
the table with a conl passing beneath it from one knee to the other, 
■ block lieing placed lengthways between the knees to keep them 
safficiently ajmrt. Thu statf is to be retained in the male urethrsi, 
mnd secured iu its place bv tying a loo]i of string round the penis 
and fastening it to the handle of the instniment. It is neces^ry to 
Ilex the knees, when the thighs are bent, in oiiler to ivniove the 
tension that would otlierwise occur in the hamstrings and sciatic 
nerve.] 

External Appearances. — In the male the skin is of a darker 
tint than that of the rest of the iKidy, and is more or less covere<l 
with hair, which should be removed. In front will lie found the 
terotum, containing the two testes, and obscuring at (iresent the mot 
of the penis and deeper portion of the urethra. 13ehiiid the scrotum 
ia the auiu or orifice of the Ixiwel, and between the two is the true 
pennaum, which will be seen to lie marked by a median niphe. 
Aronnd the anas the skin is thrown into folds, which may lie much 
enlarged iu one variety of external piles. By drawing the onvva 
qpen, a white line will be aeeu aliout half on inch above the luoi^m 




aiK ndtod ia 




kin villi the 

Ldaujt tbe I 

■ic tonred eiiO<c- 

tmijani, two Ua 

the rt^imk. Thr n>o Ub 

tke m julum f eUi in the 

are eaBliaaaiM tiam 

of the &i-t«ici^ 

i^if lastkllf iBca ia this Tiev)L IW 

baekvards to the patsw 

' of the pai■Baa^ whoa ther nc aaited br the jmMia 

la a ftauik vh« has aot hona chiUiui, a unall Imb^ 

; loU ef iaaooa» aifaitaaiii nay ba wea jna wilhia iW p«» 

' tmmmmnix, vhidi i* ealM the famrdulle, and lietavoi Ik 

I M Ihtfomu aoncalaru. 

^ f^wt iag the labia the dtbru arill Ic «««ii at tli« upper |aK 
of the valta, ntpiwhiing a dtBUBBtire penit in ajiiitataDoe aal 
e, aad having oalr a small ami ill-defined fUtna and ynyna, 
. DO BRtliral perfocatuA. 

lite nymfiia or labia fwtaerii extend oUiqnely downwanb bma 

^ each aide of ifae cliUrrif, lieing cunnectnl both willi tlic oi<giiii ittclt 

and it* pnr}>uc«, and are lost in the labia majora abuut iui<lwi]r 

between the anterior and posterior commiasuieg. 

Hie vatilttdt is a triangular iQter\-a], with the apex at the 
ami the Ijom; at the orifice of the vagina, the ^ides bvin^ formed 
ttie ii)'ini>bs. An inch Wlow the clitoris is the iii<(i<u4 urinai 
the uiarKio "^ which is tlightly jiroininent, and ia placed imninfi-' 
ately alx've the orifice of the vagina. 

The tntianee of the vagina may he raore or less occluded 
h]f7run, which is a reduiiliuitiun uf mucous membrane, usiudly 
crnKcntic fonn witli the concave border upwanls. The roi 
myrtijfirmri are little projections from the vaginal wall left by 
nijilnre of the hymen. On each ride of the vnjrinn, midwny Iivtweeii 
itH ftiitcrior and jxisterior walls, immediately in front uf the hyi 
or itji rcniiiiliH, arc the orifices of the vulco-fitginal ylaiida (or gl 
liurtholin). The orifices of numerous sebaceous follicles will 
be fduiid BCttttered over the vulva. 

Tiie liimueH nejiurutiiig the lower ends of the vagina and • 
are kimwn iik the ptrinaal body, and Bomctinies under the ill--. 
U-nii of |ic<rin(vuiii. The base of the pcriiiacal Inxly, formed \y\ 
itiU'ifiuuvul intervening lielweeii Uvc poslenoi toviviv>\*»wt«t o^ 



TUE PEUINi-L'M. 



231 



the Biuu unlic*-, u from an in«:b to au inch an 1 t hdlf 
f, bat beootnaa Rt«*tly rtretched durinf; labour. Th' ti:ip r 
Jd be iatrodu' i.'ina to urerUiu tlir jmsiUon and 

I oonditton of Ui« c. . . ri. 

BonnHariw of Ul« F«rtn«um. — Th>:*c an< thr kimr in both 

a&d caa b« best a«ic«rtAUK<d Xty jilki-ing a [m^Ivi*, mi wliirli tha 

) an prtaenred, io the miu« ]Kw»tii.>ii a» the »iil>j<'ot, whan 

■Mler examilMtlon will K- -•'' u )-> cti-'m-'H'I »illi iha 

a{KrUu« of llie {iclvia. bia, 

itEXssnl. ucliia-jiubic r.' .4 nf 

iJ!iJfih_feriu tlio lalf 1 • ibc 

■ (■ .1. - ....,, gjj, ,,, „ 

; ilyiUfe I'f 1 

tllc iKi~:irn'jr uxc--il iiiiiU i>f tlie v^>ik<' us tUc t^xlremltjr of t^e 



ill iw iMtirnt 

li ; iind fonu- 



e petiiucuui \utt beeu grDcmlly cuii-tider«<I to rek-nilili; thr 
bnsldic UiiDMige, but hwi uiorr ajillv ln.-ii I'lijiijinrvil to ;iri invitrtrd 
aoa-cX-bMUt«. The iufrrior ixyir ibr 

fuula tbaa in the nuUi-, but >. -|>ar« 

betwvcn tb*" r.iliii of tli« jiii)n-> wili Im- t'ouinl in ililti'lfiil itiilivuiuala. 
A» a rule iLi' subpiihic aiigb.' is our of Do' or morv in Ibo fuiuult), 
bdl ia kaa than a rt);bt angle in tlic* malu. 

The ptaituml apuct* may bv conveniently Jivldixl inlo halves, by a 
line jiaaiiTig from the anterior border uf uiil' tuburoaity of th* tacllium 
' c oOtcr ; the anterior or un^tltnil bulf, the periiuaum ytvptr, 
ini tJte urino-jjvnital oi^^ns, luiii the |vi!iti>rinr b»lf, or uckio- 
rtgioH, tlia lower extremity of the Uiwrl and the incbio-rcntal 
It will b«< <«««<n, hnwiivcr, that tbi» nrbilrftry line doe« not 
iiie «iui " 'liK truo uniilutnii-al limits between the two 

U of t. il KtruciureB. 



Posterior Si-ace ix iiotii Rkxes. 

ttnn-word is to be introduced into the rectum, and the 

' uUy sewn \i]), Ibe ^litcbea U-ing placed iin near the 

lied above im iKjwilile. A trumvei-^' iiiciBiou In 

t lu^ii- in (lout of the uniiK, cipniu'i'tiiig the two tul>vru«i- 

a tiiiiilar one aci^xn the lower extremity of the ejiccyj. 

to be joiiieil by n vcrticnl inedijin incixiuii, which »t tlic 

into two parts to •urrouiul thut (irifice, elui^e to the sulunu, 

I tkxD is to be reflected on eiach aide.J 

ati^umenl surrounding tlie anus is pigmented and beHet 
mbJ }nr^c gehuceoua follich'n. It Jiioreovcr pnsieASCfcl 



232 



THE PfiRIN-iEUM. 



scattered Imiulles of eninotli mueciilar fibre (corrwgator cinfa ; 
conli:iuoiis witli the dartos of the SLTotum ami perinwum ; 
smull lujTow.s which nuliatc from the anal aperture. The veini i 
this region are vciy liable to vnricose dilatation. 

The External Sphincter Ani (Fig. Ill, i6) siirromids 
anus and lies c\o»v beoeath the skin. It consists of two syrametrid 
halveJi, which are attachtd to the tip of the coccyx behind, and mq 
aliout an inch in front of the anus at the tendinous centtv of ' 
periniGum ; some fibres encircling the nniLs without attachnienl '. 
bone. The mu-^cle closes the lower end of the bowel, and is tupplii 
by the infcrjiir hoimorrhoidnl uktvc nud by a branch of the fouil 
sacral ncrv'e. 

The Tendinous Centre of the Peringeom is the name appli^ 
to a spot in fiwit of the aims, coriesponduig to the point i;f Dic«till 
of tlie sphincter ani with the bulbo-cuvernosi and transversi peril 

The Internal Sphincter cannot Im; seen at present. It is men 
a thickened baud u( tie inistriped circular fibres of the rectum, i 
dilfera therefore in structure from the external sphincter, which is I 
voluntaiy nruscle. It lies above the Utter. 

[The edge of the gluteus nmximiis is now to be defined, since i 
forms the l>oun<liiiy of the dissection ; it will lie f<iiind extendi] 
obliquely upwaiils and outwards (in this position) from the tip 
the coccyx. The fiit filling the intei-space between the anuf} and 
edge of the muscle (ischio-rectal fossa) is to be carefully reniovd 
piecemeal, care being taken to presei-ve the inferior htenioirhoij 
vessels and neiTe, which run transversely towju-ds the bowel, 
also a little bninch of the fourth sacml nerve near the po-<(terii>r i 
fil the spac*!, a.« well as the Bmall sciatic nerve and vessels wnij 
escape under cover of the muscle. Other bninches of the pa' 
Tessels and nerve may be seen i-uuniug forwaixls towards the serotu 
and idiould be avoided.] 

The Isehio-reotal Fossa (Fig. Ill) is the space on each 
of the rectum, bounded sujierficially by tlie gluteus iiuuiiuus, uch| 
tu1)eroflity, and gi'eat «jacrj>sciBtic ligament Ijchiiid ; liy_lb'-; j.iiuct 
of the fascia of Colles with the triangular ligamuiit&inXront, and 
the sphincter ani internally. Its deep boundaries ore, on the inn 
side the levator uiii and coccygeu.i, and on the outer side ilie obtnr&fl 
internus lying on the internal surface of the wall of tiie pelvis, 
these muscles are covered by processes derived from the pelvic (b«ci^ 
that covering the obturator and coccygeus being called the vlifur 
ftiDfia, and that iijion the levator ani beiug the amil fatexa (t 
iVmgraiu of pelvic fascia). When the fingai ia ^wisktid. into tlusi 



THE ISCHIO-RECTAL FOSSA. 



238 



II U armtcil by ilic juncliou of iLt-Jiv two fiuciu) ubove, in frout. 
Mad bcluiiH "^ui'i riarly il i-xtciiils to a liuptti of from two to tliTKO 
iodic*, wli ily it nmy be tmccil fonviuil iitttrly as far aa 

the symjili ' liir IctJgu ol ti&iin's constituting' the pc^hnnnmi 



rig. III). 




• ; luiil posteriorly it ruua for nonie iliaUinco ovi-r tlie iuicro> 
L'^'nnir-utg to tilt? coccyx. The fo^n tlirn iii ]>yr;iniiiiul iii 
fnintul fecliuii, arivil-hlui]Mil in s;i>;iltul ii'cliim ( Kij;. 1 10, 14). 
The epitce it lilU-il witli luow.- gi-.uiuUu- fut, which in travonted by 



Tig. 110.— Uiifnmmuticwclionor the iierinivoni nitfl urhio-nnital fowl, to the 
left of the modioji lini' (W.A.). 

I r<T^'.'nii<. 1:!, Li'iratar iini with ita fiurim. 

It. Inchiit-wrtnl foMa. 

1.5. (<l,i rtlUS. 

Iti. !>' i iutenjMico with 

.^ -, : ltsum penudii, 

17. Fiuv'iu lata of thi^h. 

lit. 8u|ii>rtiriitl triangular li^pimont. 

\'J. Mimclvii i>rthii(h. 

30. Su;)«rflciui iicruuritl vblerifutrt 
with muKira of pcuia. 



: ligamcul. 

<lio li|p<iniiiit. 

I 

illr Ugamvilt. 



234 



THE PEKIN.EUM. 



the inferior liwmorrhoidal vessels and nerve. On llif oui 
and lying above the inner border of the ischial tulieroaity 
falciform process of the great sacro-sciatic ligoiuent, nre found 
pudic ves-stls and nerve giving otf hojiiiorrhoidal nnil jieritii 
brunches, (aid lying in a fibrous channel (canal of Alcock; formi 
by the obturator fascia. It is here that the artery can be effecti 
compressed in cases of haimorrhage after lithotomy. The perini 
lirunches of the pudic artery and nerve leave the main trunlu iir' 
the anterior port of the ischiorectal fossa, but will be better setn 
afterwards. 

Surgery. — The tifvsues in the ischio-rectal fossa arc more or !« 
involved in tlie sevend forms of fistula in ano ; and the sjihincl 
ani, togctlier with some of the fat and a small branch of arter 
will lie more or less divided in the oixlinai-y operation for the cm 
of that affection. In the operaliou of lateral lithotomy tlie Id 
ischio-rectal Ibssa is cut into, and care has to be taken not to injulj 
the rectum on the inner side, the pudic artery on the outer sij 
the bulb in front. 



The Levator Ani Muscle (Fig. Ill, 18) arisu -within 
pelvis. It is attached to the back of the o» pubis, about an in 
lielow the crest, to the inner surface of the spine of the ischium, 1 
to the " white line " of the jielvic fascia, a fibrous band, which i 
stretched between these Iwny points and coincides witli the sej 
lion of the recto-vesical and ischio-rectal planes of fascia from til 
obturator fascia. It is now seen ut its intcrlion into the side of tl| 
lower part of the rectum, and l>ehiiid tliis into the centnd line of tl^ 
periuajum (where it meets its fellow of the opposite side in a medii 
raph^),and into the anterior surface of the extremity of the coccy 
Ita free anterior border runs by the side of the prostate ; its post- 
border is opposed to the anterior margin of the coccygeus. It 
covered on its upper surface by the recto-vesical fascia, and on 
lower surface by the ischio-rectal fascia, the two lamino) meet 
at its free anterior border (Fig. 110, 12). 

Tlie levator ani supports the alKloniino-pelvio viscera, and, vrhf 
in contraction, hel[>N to compress them, and so takes a part in tt 
expulsion of their contents. It is also an e-xtmonlirmry muscle 
expiration, since it assists in forcing the viscera into the concavi^ 
of the dia])hragm ; and it may compress the pro.static veins, unj ( 
conduce to the erection of tlie penis and the expulsion of the 
prostatic secretion. It is doubtful whether it has any direct influ- 
ence upon the anal aperture either as a dilator or constrictor. It 
is mpplied by branches from tUe third amV town\x sactsA. •nuitvts. 




INPERIOR U.«MORaUOIOAL AUTKKY. 



235 



Inferior Haemorrhoidal Artery (Fig. Ill, 13) 
from the intvrnal imdic artery uiulur cover of thi; iscliium, luul 
takea a tifurly (ranaveme cuune aiwurJH Ui thr UMiu lUiil lower 
eu<l nr the rtrcluui, when; il uiiiutuuiustiM with tll« iitiildlu Lioiixir- 
rboulol Lmncb of tlto iutcruui ilinc. I'mie amiita riui nilli the 
kTUay, mkI join the jiudic vein. 

FiK. 111. 




k. 



[A varicoeu condition of the inferior hajmorrhuidiil vaiun, where 

beneath the miii:«ii8 nxitubrano of thu liiwur end uf the 

iind uroinid the anal niiti'iriii, conjititiitcH the allWtion culled 

rhoidi* or piles. The enhirned ve.4a<-l» may 1« ligatured, or 

t*\ uway with th« «ui>erjaceut luucoua uiuiubniue. 



F"i(C. 111.— Suparflriat diucction of male perinicuDi (drawn by J. T. Qny) 
Infpnnr pudenilul iiervr. 
Unrthr*. 

£itvniitl or [Mwtrriar ni]ierfic]Al 
jirriniMil uvrrr. 



iljM-rituuU urtfi't. 
jii. .,. ...yrr (if •uperfiriHl ftuiciii 

tcdoctcd (Fttuia of t'ollui). 
Intiwtftl or Kitt/'riiir Bu|Kitl!rijil 

tariiiiml nrnre, 
IlullMfraTrniolU*. 
ICnamlar bruaeheft »f pudic 

lurrr. 



10. l»Jiio-cavemo«iit. 

1 1 . I'uilii: artery uiid n«r«e. 

12. Deep perinieal fuMxia or trioiigalur 
liKiitneiit. 

Iiift'riiir hivniiirrhaiilal iirtery anil 

lll'I VI'. 

Uiii" ' "'■■ •l.-i'ii layer of 

< I uiwia roond 



i;t 



14 



I'i. BriuM h t'f Injrth 'U..rul iiervf. 

Hi. SpUin' ter am. 

18. berulor iiui. 

I'O. Gluteus nutximu*. 



23G 



•J'HE PERINEUM. 



The Inferior Hsemorrhoidal Norve (Fig. Ill, 13 
branch uf the intcnial jiudic nerve, or may arise sfcpirati-lj" fi 
the lower part of the Rueral jilexus, takiug the snruc course u 
the pudic nerve in tlie same ftheath of fascia. In tlie isthio-rtc 
fos?a it runs transvergely superficial to the inferior heouionhoir 
veesels, and is distributed to the external sphincter and »kili 
tlie anus, gi^'ing a branch forword to join the supcrficiul peri 
nerves. 

The Perinaal branch of the Fourth Sacral nerve is of small oa 
and not readily seen. It appears at the si<le of the coccyx a: 
piercing the coccygeus muscle, and is distributed to tlie exte: 
sphincter. 

A yierfaratiwj cutaneoui bmiich of the sacral plexns, which liat 
jiassed through the great sacro-sciatic ligament, is usually fou: 
winding round the edge of the gluteus niiiximus, from the 
rectAl I'ossa. 

Akterior Space in the Male. 




[The scrotum being dmwn up with hooks, an incision is to 
made in the median line, extending from the central point of 

perina-uni to within three inches of the extremity of the p« 

The »kin is to be reflected to each aide, and the testicles held out of 
the way with liooks.] 

The Superficial Fascia of the anterior half of the perinteuml 

divisible into two layers — superficial and deep. 

The superficial laijcr of superficial fascia is continuous with 
of the scrotum, and like the hitter is fatless and contains a la]i 
of iuvolunlary ujuscular fibi-e, the dartos. 

The deep Imjer of superficial fascia (Fig. Ill, 6) or Fa»c\a\ 
Culles, is brought into view by the removal of the superficial la 
OS u distinct membrane in thin subjects, but is not easily defined] 
fat ones. It U continuous in front witli the fascia of the scroti 
and penis, and over the root of the penis with the fascia of 
alxlouien ; laterally it is attached on each side to the imuxin of 
ischio-pubic rami as far back as the tuberosity ; and posteriorly tu 
around the tmnsversi perinaji muscles, and joins the posterior bor 
of the deep perinteal fascia or triangular ligiuncnt (Kig. 110). 
pouch, which may be called the guperficial perinienl ; 
thus formed between the fascia of CoUes and the triuin 
ment, and encloses the root of the penis (the bulb ot the 
pus spongiosum luid the crum of the corpora cavernosa) with 
surrounding muscles, vessels, and nerves. This interspace is of i 
l>ortJince siiiyically with regard to extruvasaWotv ot wruift. \l «o3 




THE PERIK^UM. 237 

rasation should occur from rupture of the bulbous or ailjauent 
portion of tlie urethra, either from extemul violence or from the 
unskilful use of a catheter or other cause, the urine i» efru8e<l into 
the pouch, and, being prevented by the union of the two fascia) 
IKMteriorly from running back to the anus, anil by their lateral 
attachment to the rami of the pul)es and ischium fmm extending 
on to the thighs, it necessarily distends the ]M)uch and creeps into 
the scrotum and groin and on to the abdoiuuu. 

[The deep layer of superAcial fascia is to lie removed, and the 
■nperficial perinical vessels and nerves di.iiHicted out ; care being 
taken to preserve the superficial tmiisversu muscle, which runs 
outwards from the central point of the iH.'riiixuni.] 

The Buperfioial PerizuBal Artery (Fig. Ill, 5) is a branch 
of the internal pudic, and arises under cover of the ramus of the 
ischium near the front of the ischiivrcotal fossa. It enters thi! 
raperiicial perinoail pouch of fascia by jiii^rcinj; its hindtT bonier, 
and then passes forwanls, over or under the superficial trnnsvc-rsus 
perinsi muscle, to supply the sniierliciiil muscles of the purinajum 
and the integuments of the sci'utuiii luid anastomose with the 
external pudic arteries. 

The Transverse Perirueal Artery (Fig. Ill, 11) is a branch 
of the internal pudic, arising imnieilialely in front (if, or with, the 
prvceiling vessel. It runs towards the median line clo.se to the 
superficial transverse muscle, and anustuuioses with tin; opixtsite 
artery and with the neighbouring l)ran('lies. feiiu corresponding 
to the arteries open into the internal ]iudir vein. 

The Ferliuaal Kenre (Fig. Ill) generally Icives the pudic 
as a single large trunk in the ischio-rectal fossa, and supplies two 
iuperficial perituEol nerves ; miincuUtr branches to the (txternul 
sphincter, levator ani, and the three muscles in the cMri-esiH)iKling 
hfdf of the superficial perimcal inters]iari; (tmnHversiis ]ierinici, 
iachio-cavemosus and bulbo-caveniosus) ; and a brunch wbicli may Is; 
followed through the accelerator urinju to the bulb of tlie \irethni 
(bulbo-urethml nerve of Cruveilhier). 

The tjleriud or poMerior siipcrficM {D-iimrul (3) nerve has a 
short course in the ischio-rectal fossa, wlien; it gives a bnuicli to 
the anus. It then pierces the reflection of the deep layer of sujMir- 
ficial fascia, and gives bnuiches to the .".erotuiii, t'oriniiig a junction 
with the inferior pudendal nerve uiid usually with tiiu inferior 
hsemorrhoidal nerve. 

The internal or anterior (j) nen'e accomiKinies the A\\\>tTVvt\8\ 



238 



THE PEBIN/ECM. 



erinieal arterj' either over or under the trunsversus pi'nua.'i mn 
nd is diBtributcd to the scrotum near the iue<lian line, when i 
unites with its fellow of the opposite side, giving aUo one or tir 
snmll limnclies to the levator ani. The before named muteular i 
unlhrnl twigs may spring from this branch instead of from 
perinu'iil trunk. 

The Inferior Pudendal N'erve (Fig. Ill, i) (Socninieriux) I 
ft branch of the small sciatic nerve, wliicji pierces the deep LvkU 
of «lic thigh about iin inch in front of the tuberosity of the Lwhiaii 
It varies a good deal in size and distribution, but genemlly nin 
inwards and forwards to the scrotum to join the external auperficiil 
perinatal nerve. 

[The superficial vessels and nerves are to he turned aside, and 
tht- muscles di.ssecteil out. The accelerator urinoB is in the mcdi« 
line, the erector penis ^xirallel to the nimus of the piilies, and th 
trmisversus jierinad crosses between them posteriorly ; the luusch 
tlitLs Uiunditig u triangular space in which a port of the tria 
ligament is seen.] 

Superficial MuscIeB of the FerinsBUta. 

The muscles in the superficial perineal interspace are im 
each by a fa-scia proper to itself. 

The Bulbo-cavernoBUS (Fig. Ill, 8) {fjaetilator leminis ore 
iii/»r nritur) is a single muscle, composed of two symmetrical \iaXv 
united in the middle line by a delicate fibrous raphe. The fjbn 
iirvte from the central point of the perinteum and from the tibinq 
ruph^ superficial to the bulb, anil are inserted as follows : — the ' 
lerior fibre*, which are nearly transverse in their direction, over 
the bulb and are lost upon the superficial triangular ligament ; tt 
middle filircs encircle the corpus spongiosum and meet those of lb 
op]«i9itc side in a median raphi? under cover of the coritoru 
iiosa ; and the anterior fibres (inconstant) pass obliquely out war 
!in<l forw-anis, enclosing the entire circumference of tlie root of the 
penis and the dorsal vessels {eovtjtrcsnor renie dcyrtaiU). 

The Ischio-caTernoBUB (Fig. Ill, lo) (erector penit) a pair 
muscle, covers the cms penis. It arises from the anterior 
inner surface of the tuberosity of the ischium, from the riunm 
the ischium and also from the fibrous origin of the cms, .ind end 
in an aponeurosis which is inserted into the sides of the cms pen 
and sometimes .lending a slip over the dorsal ve.s8els. 

The TransversuB Perinasi (Fig. Ill, 14), also a paired muad^ 
is very variable in its character. It urisea from the inner side 
tJie niHias of the ischium, and runuinv^ totwaTda aaA v\v«t&vd& 




THE I'EKlNiUUM. 2'W 

its fellow muiicle of the opposite side in the ci-iitrul ]H>int of the 
periiuEniii, where it often blends with tlie tibivfi of thi- accek'mtor 
urinte anil fiphincter ani. 

The action of the hullio-farfrninuA is to cxik-I thi' ••iinti-nts of the 
urethra by itH siuhlen nml nimsmiMlic contnkrtinti. It is not put in 
action during the ^^ater ]>nrt «f tlie art of mictiirition ; but when 
the flow of urine hiu* ceasvil, it servex to t-jci-t tlie sniiill reiimiiiin); 
portion ; or it may be used to am-st the llnw nf urine siidilenly, when 
it« action ^lives rise to t;on!>iiIembh> ])iiin. Iih action during; coition 
is es]iresse<l by the name ejaculutor Heminis, and its anterior tilires, 
when present, aid in proilucin^ eti-ction of the pi-niA liyi-oni|ircRsin){ 
the dorsal vein. The inrhio-rnrimmi may asiist somewhat in tlie 
production of erection by <'.ompresHinK the roqius cavernoMun, and 
more dinwtly by conipivssinj; thedorval vein wlieii its aecessory nHp 
is deTelo{ied. It may, too, im[iress souk- vulunlary motion upon 
the penis after erection. The trtintnrifi furimri aid tin- action of 
the bnllxM:itv«:niosuH by fixing tliu tendinous centre of the ]>uri- 
lunim. 

Surgery. — The triangidar spucc bounded l>y tlie three siiperticial 
iiiu«<:leA is ini{x>rtant siirgicdly as Ihmu^' the ]ioint to wiiicli the 
knife reachex in the incision for hiteral lithotomy. In the lir.-t inci- 
sion the surgeon cuts freidy through ihi- su|ii-rli<'ial >triictures, 
dividing the smiierticiul ^n'rinieal and interior bieinorrhoiilal 
vessels and nerves, and aiming at the lower ]>.'irt of tliis s|iiice, :it 
which ]>oint the linger will feel somewhat indistiiK'tly tlie stall' in the 
urvthm. The deeiKir incision nece^s•l^ily diviiles the tiansverse 
^lu^>cleand artery, together with the biwer ]iart of I lie triangular liga- 
ment, ami enables the o]ierator to reach the stall' in the nieiiibranous 
portion of the urethra. 

It should be noticed how the Hmall interval between the ;iiiiis and 
the bulb of the urethra can be inc.rea.sed by drawing the. whole jH-nis 
upwaid.o; this fact is of imiMirtance in relation to ineilian lithotomy, 
vhieh is performed in this H]iace, and in which o|ieration there is 
rame risk of wounding the bulb. It is obvious tint any cutting 
operation in the median line of the ]K-riiiieuin woiiM be aci iini|niiiieil 
by but little hxmorrhiige, until the vascular hlructiire ol the bulb or 
ourpns siwingiosiiin urethrii- is reached. 

[The bulbo-cttvernosus is to be dividul in the miilille lim-, anil 
dis.<iecteil fnira the bulb iH-neuth and from the triangular liifaiiient, 
but its anterior tibrcH must not U; intcrlen-d with. The tiMii-ver^iis 
perintei is to be removed, and the isclno-iaveriio>u> detaclie<l Ironi 
the bone with the cms penis, which will 1h^ to-en to be attacjieil to 
the ischio-pubic rami for nearly an inch. The cni- i.^ to be iirawn 
forward, a branch of artery gciiiff to ii being carefully \iivs«',vve<\ ; 



240 



THE PERINiEUM. 



the i>up<>rficial triangular ligament will then be expoaeil. It mwi 
well to leave the crus penis iindistiu'lied uti the rignt siilc] i 

The posterior part of the Corpus Spongiosum tJrethrB will 
1)6 seen to l)e a dark, vascular Ixxly, which expands to form 
bulb, immediately in front of the triangular ligament. 

Pig. 112. 




The Bulb (Fig. Hi, 6) is »! ighlly expandal liimi side to aide, « 
consists of two halves united by a delicate septum of fibrous tissn 
It is closely connected above with the triangular ligament, witj 
which its delicate librous covering is continuous, and is embrucetl I 
the two halves of the biUbo-cavemosus. 

The Superficial Triang^ular Ziigament or Deep Port 
Fascia (Fig. 1 1:!, 8) is a ^trojig process of tibrous tissue stretch 



Fig, ll'i. — Deep dissprtiim of the raalu perinu'um, the aoterior triuigulor Ii| 
laent being removed on the right nido (drawn by J. T. Gray). 

6. Bulb of urethra. 



1. liijrht cms penis (eut). 
'i. Left crus penis (cut). 

3. I'udic nen'if. 

4. Deep layer of Huperticinl fiucia 

reflected (Foaciit of Colic*). 
3. Pudic Hrterr. 



7. .Aj-terv of the bulb. 

8. Superticinl tiuin|,'ular ligiimrut.1 
U. Deep truiisversua periliitd muirlr 

10. Position of Cowper's 
(right). 



DEEP PERIN-KAI. FASCIA. 



2il 



• the paWo ttwh, beiiiK mtacLed to the nimi of tin- o« |mbU 
•ad iadiiuui on eath siiic, b.-hiiiil th« cnira p«ni*i. It in almorit 
borixoitlal in the crvct ]>(.>iittia-. 

The opi-x of the lij,-aiuent is iici«niUtl from the »ul>-imbic ligur 




m- ' ' !iitv fur till- ilormil vuin i>f ihi- poiii" ; iiml llii* Imixj, 

« i III of iiu iuvi-rtitl V with the umkI'' ut thu li-mliuutia 

ce&lrc ui tlic ptrinKUiu, ia conlinaouii with the fMcia of CoUei wbeiu 

r" '■ Ttteial and <lr<'P triiuiKuIar liiracaents (W.A.). 

1 rtnrti 13, Ap'rl iin' for nrtf ry to bulb. 



' pt. HI*. 

:i iiili'ry mntl 

4. r>op«l twryt. 

a, Cru< pmi*. 

0. Aiiin-uv lajer of triitiiirul>r Mgn- 

mrnt. 
7. Aperture fcrr artery uf <«rpuii 

cariTnoMutfi. 
S "'--i -■-■•■ '.....■- 
S- 'i^meiit. 

«i • nl. 



•tma. 



H ArtiTV tobulb. 

15. Ilrrthntlapi-rtur*. 

10. Piitlic ri'in*. 

I". .\|H>itiiro forCowpcr'i duct. 

IK. Dunuil iiurvL. 

I», Viu>\- ■■ ' '•■". 

20. rooii ..r'« irliinJ. 

21. .\lii 1 1 |ii'i'Urml pwilwal 

vo«iu. la uuil iirrve. 
T2. Intt-nml puilie iirtrry. 
23, Fiiw'iii n( Collmt lurii«<l iMnk- 

wiiriU. 
24 rmtpriiir burtler nt {icTintcaV UA«;e 

(jiinelioii o( triunKu\ar Ui;*,- 
iui';it« with fusciii o( CtiWtt). 



242 



THE PERINEUM. 



this turns around the superficial transversi perinaei, and also ' 
the base of the deep triangular ligament. 



Fig. lU. 



fj 



— * 



— t 
— * 



11- 

J3- 
16- 
17 
10- 




ir ."-V, . i»*l' i^^. 



It is perforated about an inch below the 8_vniphysU by tljc uie^ 
bianous urethra ; above this point, close to the puJic rami, by ( 
dorsal arteries and nerves of the penis ; and slightly behind 



Fi«. 

1. 

2 

3! 
4. 
6. 

6. 

7. 

K. 

9. 
10, 
11 
12 

13. 
14. 



;, 114. — Vertical frontal section of the pelri*, abowing fascia, modified : 
llrnune (W.A.). 

IS. Pubio areb. 



Bladder. 

While linp. . 

Uvulu veflicc 

Subpfnloncol fat. 

Proitatc. 

Obtunilar iutcnitu. 

Verumontunum. 

lacbiu-rei'tul fnscia. 

Lovulor uiii. 

()8 iiuioininntmii. 

Aleiiibmiiutia urethru. 

IWcto-viiiioii fimiii, parietal and 

visconil luyen, 
Pudic iraw'U. 
Obturator fatcia. 



16. Obturator membrane. 

17. Fanc'itt of isohio-caTernodu. 

18. Idvhio-rec'tal fossa, anterior riti 

sion. 

19. Crus penis. 

20. Deep triangular Ugnniect. 

21. Bulb. 

22. Ueep transversns perimci. 

23. Bullio-cKvirnmus witli ita fit:_, 

24 . SuiiiTtiiuiil trianipilnr lignnimt 
'26. luti'gunicnt. 
26. Muscles of thigh. 

30. lHuscVc* ot V.Vvi^'h. 




cx)wper's glands. 243 

external to the uietbra on each side Ity the ihict of CowpvrV glandx 
and the arteiy to the bulb (Fig. 113). 

[It ia aalvisable sot to proceed any further with the diKSfclioii of 
the left «idu uf the {)erin;fuin, in (irder that a }{oihI siih- vit-w of thin 
ief;iou nuiy 1>e obtained in a suliKequvnt dis.'<c<'tiiiii. On the ri^ht 
side the miperficial trianguLkr liKtuuunt is to be I'liri-fiilly detai'licd 
from the bone and from its attaehuientx 1ieb>w, and turned towards 
the n)e<lian line ; the bulb nhould also bu drawn over to the k-ft 
side with the hooks, so as to increase the H])iii;e broii^dit into vi);w as 
much as posMble. The minute structui-uK Iwhind tlie superfivia) 
triangular ligament are then to be carefully dissected.] 

The deep perimzal poueh or iutertpare., iMitwi-en tlu; supvrticial and 
deep triongnlor ligaments, is now opened u]i. The enntcntH nrtt the 
deep transvenus periniei (compressor iiretline) ; the mciubnui- 
OUB portion of the urethra ; C'owper's ({lamls ; jxirtiuns of the pudtc 
vessels and dorsal nerve of the penis, and the artt-ry to the bulb. 
The sub-pubic ligament and dorsal vein <if the {lenis lie at tlur 
anterior angle or apex of tlu; iMter<]Hiec. 

The Seap Tranaversua Ferinaai or Compressor XTrethrn 
(Fig. 112, 7) arinet from the inner surface of tin- iwliio-jmbie rami, 
between the attachments of the two trian<;uhir li};anioiits, and divi(U-» 
into anterior and posterior sliiw, wliii-h nm inwanls tnui.iver«»ly 
»CTf»n the median line to encloite the iiivmbninous portion of the 
urethra. Within the fibres of the i-onijircssor oji wich Riil« are 
(1) Cowper's gland, (2) the jmdic artery, fjivinj,' off the artery to 
the bulb, and dividing into the artery to the corpus cavcntosum 
and the dorsal artery uf the penis, (3) the CMrrcs]Hinding veins, and 
(4) the dorsal nerve of the penis, a branch of which supplies the 
muscle. The duct of Cow])er's ghin<l and the other structures 
named have been seen to pierce the 8U))er(iciid trian;{ular ligament 
to reach the superficial pouch. 

[The muscular fibres are to lie divided near the urctlira in oiflcr to 
see one of Cowper's glands, and the pudic artery and nerve M'ith their 
blanches are to be followed out close to the iscliio-]iu)>ic rami.] 

Cowper's Ohuids (Fig. 112, lo) lie dose to tlic- membranous 
portioa of the uiethia, one on each side of the median line, and 
are most readily found by tracing the small branch of supply to 
each gland from the artery to the bulb. The gland resembles a 
pea in size and shape, and consists of numerous minute lobules. 
Although it is so close to the membranous ui-cthra, the iluct pierces 
the superficial triangular ligament to open into the bulbous por\.\ou 
€»f the cmomI, Mod u nearly an inch long. 

K 2 



244 



THE PERtN.«lTM. 



The membranous portion of the iirothra will be more Mtu 
torilj' examined nfterwards, but opportunity sbould be taken 
feel the staff in the urethra at this point, since it is here that tiih 
would be opened, on the left side in the operation of latewl lilljo 
torn)-, or in the middle line in the median operation. 

Fijr. 115. 




The Fudio Artery (Fig. 115, 9), one uf the two temiiiul 
brimches of the anterior division of the intenial ilinc, will 
found under cover of the pubic arch. After running in Ale 
canal (p. 234) in the outer wall of the ischio-rectal fossa, 
giving off it« inferior ha;inorrhoidal lUid superllcial periu 
branches, it pierces the deep triangular ligament near its base 
enter the de«sp perinuial interspace. liete it runs in the 



rig. 116.- 



-Artoriwi iif the prrinniiini (fi-oni WilBuii)- 'In the right «ide I 
aupcrrii'iiU urtc-ric6 are even, on the Iclt the deep. 



1. The penis; the cnis penis <if the 

left «de ie cut throuRli. 

2. Acralerutor urinie muacle. 

3. Kreftor penis. 

4. Anus suiTuuniled by the »phineter 

nni. 

5. lUuii (if itt'hiutu and pubes. 
C. Tuberosity uf ischium. 

7. Le«er sacro-scuilic ligunient. 

8. Corcyx. 

0. Internal pudic aitery, criwsing the 
tpiue ot the iarhium xnd enter- 



ing llie perinieum. 
111. Inferior hicmoirhoidal l.iiiiiih. 

11. Superliciul pvriniea! 

oil' iho tnin»vM>. 

the trufHVer>us pci ui it iim- 

12. The Kiiiiie iirterv on the left i 

out otf. 

13. .Vrury of the bulb. 

14. The tirtery of the rci-poi cMT 

sum and the daiatl 
the [lenii. 




THE DEEP TRIAXOULAR LIGAMENT. 245 

of the compKsaor nrethne, close to the ischio-pubic rami, and 
gives off the arterieo to the bulb and corputi cavemosuni, and 
terminatca in the dorsal artery of the penis. 

The Artery to the Bulb (Fig. 112, 7) pauses tnuisvenely in- 
wards to supply the bulb, to ruavli which it hax to pierce the 
superficial triangular ligament close to the middle line. It generally 
gives a branch to Cowi>er'H gland uf the same side. 

The size and position of the artery to the bulb var)- considerably, 
and are of iiui>ortance with reference to lateral lithotcjmy. When 
the origin is as far forwanls as represented in Fig. 110 the artery 
must be free from dangt-r, but if it should arise farther back (and 
it is occasionally found in the ischio-rectol fossa), it would be liable 
to be cut, and might give rLte to troublesome or even fatal 
haemorrhage. 

The Artery to the Corpus Cavemosum (Fig. 115, 14) 
pierces the 8Ui)«rficial triangular ligament to enter the cms. It is 
accompanied by a rein. 

The Dorsal Artery of the Penis pierces the fore part of the 
superficial triangular ligament, and then the suspensory ligament, 
to reach the upper surface of the organ, where it will Ije subse- 
quently traced. 

When the pudic arter}' is small, the dorsal arteries are derived 
from the trunks of the internal iliars, and reach the penis by 
piercing l>oth triangular ligaments on each Hide of the dorsal 
vein. 

The ]>orsal Vein of the Penis runs between the sub-pubic and 
triangular ligaments to join the prostatic plexus of veins. 

The Internal Pudic Vein receives tributaries corresponding to 
the branches of the pudic artery, and tenuinnti-s in the internal 
iliac vein. 

The Pudio Nenre (Fig. 112, 3) lies below the artery in the 
inchio-rectal fossa, where it gives off its hoimorrhoiditl and ]>erina)al 
branches, and ends in the dorsal nerve of the penis. The latter 
accompanies the pudic artery through the <lce]i ]H!rinie:il intursi>uce, 
lying to its outer side in the fibres of the compressor urethrie and 
supplying the muscle, finally piercing the superficial triangular liga- 
ment with and external to the dorsal artery. It.s course and distri- 
bution on the penis will l>e seen later. 

The Beep Triangular Iiigament (Figs. 1 10, U:)) dosuly re- 
sembles the sui)erficial triangular ligament in its mu<le of attachment 
to the ischio-pubic rami, but is placed higher and muy be reganled as 
a continuation of the obturator fascia across the sub-pubic aich. U \s 
in eoatMct Aioie with the deep tra/isvereiw perinaji, and 0601'e with ttie 



246 



THE FtaiAI-K PERIN.K[7M. 



fat of the anterior cztensioa of the iachio-ivctal foswa, the apex nf 
tlie prostate, the recto-vesicul fascia, and the aut«rior til.>rv« of the 
levator ani. It is pierced by the internal pudic vesseli and dor 
nerve of the jienis, and by the urethra. The dorsal vein i.f 
penis runs between its apex and the sub-pnbic ligament. 

[The flaps of skin i^hoiild be carefully sewn together bd'orv the 
body is removed from it." position.] 



AxTKRioH Space in the Fesjai.i-. 

[A little cotton-'n'ool is to lie inserted in the va};inu, and 
margins of the labia miynra are to be fiu»tened together by a : 
stitches. An incision it then to be carried transveively olxive 
junction of the labia, finm which two vertical incisions, as near i 
maixin of each labium as convenient, aic to !><• prolonjied to til 
central jioint of the pcvinii'um. Tlie Haps of slcin cnn now li 
rettecled from the middle line, if the trnntiverse incision l)ehinil 
the labia haf been alreatly madi-.j 

The Superficial Fascia of the anterior hiUf of the fema 
perina'um reiscinbU-s that of the male, in being diNTsible into I 
layers — sitperliciid and deep. 

The suyierficial layer of supurlicittl fascia is continuous with the 
fascia of the body generally, and usually contains inncb fat Iteue 
the internment of the labium. 

The ilerp layrr of superficial fascia is not so strongly marked 
in the male, but has the same connections. It is conliiiuou.i wiU 
the dee]) fascia of the groin, and is attached on each side to 
margins of the rami of tlie os pnbis and ischium, nearly to the tub 
rosity. It then makes a turn around the BU]ierficial transver 
jjerincei muscle on each side, and joins the triangular ligament. 

Owing to the position of tlic vulva, the deep layer of sup«r6cii 
fascia is divided in the middle line mnl becomes continuous ■ 
the sheath of the vagina ; and the pnuch between the deep lay 
of superficial fascia and the triangular ligament (p. 236) is divide 
into two parts, which have been named the pudendal or vulco-^roUd 
sacs of Broca. 

[The deep layer of sujierficial fascia is to be removed, an 
superlicial perina-al vessels and ner\es dissected out, care 
taken to preserve the transversus perina;i muscle, which 
outwards and backwards from the central point of the pcrinifi 

The Superficial Perinseal Artery (artery of the Isbiii 
(Fig. 110, 5} is a branch of tVie \nletuo\ ^wiVic ocrtKr^, mA v,\« 



THK FEMALE PEHINJiUM. 



Ul 



in the uuil«. It «rist<it uiuler cover (if the mninn of the 

»cl)itiin iind runs forwntxlii and iiiwanlii, to riitiT the p<juph of fiwcift J 
by pierci ng the huulcr bonlt-r of ilie irimi^ulur li),-uriifiit, tliea^ 

Fij. lie. 



f — " 
— *« 

7* 



' over or under the Huiwvliciul traimviTMin jwiiriioi rmisele to 
' the iiupi-rliciul uiu«<:k"i nf ihi' iM'iiiiaiim mid t)if Ubiiim. 
Tlif Transverse Artery > Fig. 1 IfJ, 4) in 11 l.>niiich of tlie intrnml 
Bdi<, urisiiiL' iiuniriliatcly in frgnl of or with the jirt'cvdiiig vusstd. 



r 


1 ig, WIS, -Tlw famiilei 


IHTiiunam (from 8ay>(a). 


L 


Pudiii »rt«ry. 


IH, IM. Dorwil ncrro of cUtori>. 1 


E 


Bruirh to K-vator ini. 


l!l. Ilio-iiigiiiiiul ncrrc. J 


K 


Infrri'ir hiL-morrUoulal »rtcrj'. 


A. Anux. 1 


R 


TruMTPTw »rl*ry. 


i;. Clitoiii. ~ 


i. 


QnM. UUaI (tupertiFiiil prriiiH-al) 


M. Mpntiin iiriiuiriu*. 




Mtrry. 


I.. Grout Ml ro-»nialii' lijptniviiL 


Ml- 


UotmI «rtrry of vlitorU. 


V. V^gimi. 


h. 


Artery of bulb. 


0. Cwryx. 


Rl 


Artcrv !-■ cni» rlitoridii. 


T. Tubi-riMity of iwbiam. 


to. 


Iiil rrhoicUl uerve. 


n. (i lull UN iMiiximua. 


II. 


I'u 


!■, l>eviitor »ni. 


L*- 


%i -t. 


d. Tr:i! ■ ' ""rinii-i. 


B 


• rinninl m-rvi-. 


/•. r... ,:i.i. 


"14 


:al JlCIIUU'll 


h. 'Ii iiornt (cot). 




liiu Viz. 


16. 


tta jutietkio »Uh — 
Infrrior podriid*! nnrvc. 


i, I)i> .i-tt'iuliiio«u*. 


16. 


j. Alii!... ; t,uu<. 


17. 


Stamll fittif aerrr. 


t. Gnu'ilii. 1 



248 



THE FEMALE PEBIN.£UM. 



It runs towarda the median line cloae to the superficial transve 
muscle, and nnaBtomoses with the opposite arteiy and with 
neighbouring liranche*. Vtim corrtsponding to the urterie« / 
into the iiiti-nial pudic vein. 

Thu Superficial Perineal Nerves (Fig. 116) a« two 
numbei-, and arc lirunohes of the pudic ner\'c. 

The internal ur aiiterior (13) nerve inns upwords and inn 
entering the pouch of fascia and being distributed to the jr. 
part of the vuha. 

The cxletiuil (It ])wfrrior (14) nerve is larger, and is distrihqu 
to the superliciul muscles of the periniouni, forming a junction ' 
the inferior pudendal nerve. 

The Inferior Pudendal Nerve (Fig. 116, 16) ia a biandi( 
the Htnoll Kcialio nerve, which pierccM the deep fiiscia nf ttie thid 
about an inch in front of the tuberosity of the ischium. It 
usually of small size iu the female, and runs upwards and in* 
to join the external superficial perinoeal nerve. 

[The superficial vessels and nerves are to be turned aside and 1 
muscles di.ssected out. The mu.icles are much less di.stinct than 
the male jjcrina-um, and it is impossible to trace all iheir lib 
without niBcenitiou and prepanilion, which it is impnuticuble 
the student ti> uiidurtiikc ; he will bu able to muke out sulficie 
however to ».-isi8t uialerially in following the dcRCriplion.] 

The Perinaeal Body of Savage (Fig. 117, 14), peculiar' 
women, consists of an clastic mass of tissue placed belir« 
the orifices of the vagina and rectum, and uniting all the str 
tures which meet in the centi-al point of the periniemn. Its 1 
apiKjars to l>e to allow of great stretcliing, without tearing, dllrij 
parturition. 

The Superficial Muscles (Figs. 116 and 117) of the (emi 
perimcum cl(«-ly resemble those of the male, with the exccptid 
that the two portions of the central muscle, con-esponiling to 
bulbo-cavernosufi, are sepamted by the vulva. On each fide the 
fore of tlie vulva will be found the half of the bulbo-cavemosu 
lying on the ramus of the os ])ubis, the erector clitoridia ; 
jiassing from the tuber iechii to the central point of the perintea 
the transversus perinasi. 

The Bulbo-CavernoBUs (sphincter vagina.") (Fig. 117, 5^ ttr»»«» 
on each aide from the ela'tic perinu3al bo<ly between the anus aa 
vagina, a few of its superficial fibre.s being prolonged into 
sphincter ani ; it olso arises from the reflection of the deep lay 
of superficial fascia (ischio-perii>a;al ligoinent of Savage) for ne 




BULB OF THE VAGINA. 249 

an inch, and decoasiates with the inner fihrex of the tranBvenug. 
The tibres of the niU8cle overlie tl>e hulbiu vestihuli ami glandt of 
Bartholin, and aiv divisible into three Ketw, corresponding to those of 
the bulbo-cavemiMUx of the male. The anterior Jil>re» ptami forwanl 
on each side of the vulva to uieel thos«> of the op]M>site nnisule 
upon the clitoris, and to be partially imurtnl into the sheath of the 
clitoris ; the middle libri's ]>asH iN-neath the clitoris and over the 
great veins upon the urethra {jiart intermediuUA, which are analogous 
to the coqius sponj^iosuni of the innle, and meet those of the opposit« 
aide ; the posterior fibres pass on to the trian};ular ligauu-nt (Savage). 

The Srector Clitoridis (Fig. 1 17, 3) resembles the erector penis 
in the male, and thuugli actually smaller in size, bears a much 
larger proportion to its organ than that muscle. It aritet front the 
front of the tnl)er ischii, and is iiiterted on the sides of the cms 
clitoridis. 

The TransTeraus Ferinaei (Fig. 117, 7) orUes from the inner 
ride of the Tiimus of the ischium, and meets its fellow muscle of the 
opp<Mite side in the centnd jierintual IxmIv, where it is blende<l with 
the fibres of the bullHi-cavemosiu and spliinctirr ani, and the deep 
part of the .iphiucter vaginoo. 

The Iievator Anl (Fig. 117, 11) is divided by Savage into three 
IMrtA : 1. The piibo-cofctjgftu, now seen in j)art, its fibres having 
the some direction as the ajdiincter ani. It ariiu* from the bai'k of 
the pubes, and its Hbivs cross the n>otum between the suiK-rticial 
and deep sphincters, ami are {iim-tinl into the siile of the lust two 
lionea of the coccyx. 2. The ol>turiit<Kik-niiiiiiK, which unVs from 
the line of division of the pelvic fascia into obturator ami recto- 
vesical layers {whitr Uiu), and is also iiimrtnl into the side of the 
last two bones of the cinrcyx. 3. The mhiit-nHyijij' iin, ront'sponding 
to the coccygeuB muscle as orilinarily described, and extending 
from the spine of the ischium to the side of the coccyx. 

[The bulbo-caveniosus muscle is to l>e divided at its origin an<l 
turned up, after Ix-ing dissected from the bulbus vestibuli bcm-atii 
and from the triangular ligament. Tlie su]icilicial tran>vi'rs\is 
perina-i is to be removed, and tin- erector cliloriilis detaciied from 
the bone with the cms clitoriilis, wliic.li will be seen to be a vascular 
Inidj attached U) the ramus of the pubes for half an inch. This 
is to be drawn forward, a brunch of artery g'liiig to it being pre- 
served, and the triangular ligament will be exposed.] 

The Bulb of the Vagina (Fig. 117, 8) or bulbus vestibuli of 
Kobelt corresponds precisely to one half of the bulb of the male. 
It is a vascular body placed on the side of the orifice of the va<^vua. 



250 



THE FEMALE PER[N.«UM, 



and enclosed in a sliculli of fascia derivetl fi-om the triangula 
meat or due|i |ierinietd fosciiu Each bulb ia about an inch long 
is composeil of a plexus of veins, which cummunictite with tb 

Pig. 117. 



fit. 



/, 





-i 

til 

r*. 


^1 


lU HO 




tlic opposite side beneath the clitoris. The forepart of the 
is soinetiiues known as the ^m''" iiiitniudialiii. 

The Superficial Triangular Iiigament resembles that 
male, and is n stnjng process of tibrous tissue stretching acroi 



Fig. 117. — The superficinl miuolea of the femiile perina'um (from San 

9. Obturator iutemua muiele. 

10. Vu^'iua. 

11. Levator ani muscle. 

12. Vulvo-viijfinul glnnd. 

13. Suhiiiotcr ani ext<'.mu.<. 
U. Tni' iicrinical body. 

15. Glut«ua maximus. 

16. Auuk. 



1. Pubea 

2. Clitoi-u. 
;). Erector clitoridis. 

4. Vestibule. 

5. Bulbo-cavemosus muscle. 

6. Urethra. 

7. Suiici'tirUl transvcrac miucle. 

8. Bulb of rnK>iia. 




PUDIC ARTERY AND NERVE. 251 

pubic arch, to be attached to the T«mi of the ok pubis and iiichium 
on each side beneath the crura clitori(1i8. It i« jierforated by the 
uiethia and is dividetl poHtcriorly by the vafjinu, with the coats of 
which it is Krmly incorponited ; it ifivea pitsgage also to the terminal 
branches of the pudic arteries and nen'i-s, as in the mule, nud to 
the large veins of the clitoris and bnlbi vustibuli, whioh iiiii>s to the 
plexus aronnd the base of the bladder. 

[Tlie superficial triangular lignnient is to be carefully detached 
from the Ixme and removed, when the deep transversus ]H-riiii(>i and the 
terminal bnmches of tlie pudic artery and iiorvc an; to Ih! dissected.] 

The Deep TruMrenua Ferine! (( 'oinim-Hxnr rn-thne) ban 
the same attachments as in the male, but consists liir^cly of un- 
(triped fibre. 

Involuntary circular fibres surround the whoh; lcn(;th of the 
female urethra, and may corrcsiiond to a portion of tin- prostate in 
the male. 

The OUuda of Bartholin (Fig. 1 17, 12) corn>s]ion(l to Cowjwr'H 
glands in the male, but are nion; suiRTticiiilly ]iluced. Kiu-li <{laiid 
is of the size of a small bean, and is situated Ix-hind the. bulb. Its 
minute duct opens on the mucous hurface in front of the hymen 
abont midway between the clitoris and ])0!<tcri()r (.'oniiuiKiiin'. 

Pudic Artery and Nerve (Fi^;. I l(i). The terniiiintioiiH of the 
pudic artery and nerve in the female corrcwjiond closely to tliom' of 
the male, but are much snuller. The artfiy lies under cover of the 
ramus of the os pubis with the nerve, and gives otf arteries to the 
bulb and cms clitoridis, and the dorsal artery- of the clitoris. 

The artery of the buUi (8) runs tnuisversely iuwanls, and 
terminates in the bulb of the vagina. 

The artery to the, rrui elitorulu (9) is vei-y small, ami is lost in 
that organ. It is aecompuiied by a vein. 

The doncU artery of the\eliti>rit (7) reaches the dorMuni of the 
organ with the corresponding, nerve. 

The Donal Vein of the clitoris is of large size, luid jmuisus hack- 
wards to open into the great vems around the neck of the bladder. 

The Pvdie Kervt (11) gives otf muscular branches (12), and ends 
in the dorsal nerve of the clitoris (18), M-hich bears a much larger 
proportion to that organ than the corresponding nerve of the penis. 

The Deep Triwngrular Ligament diifeni froiu that in the male 
only in being pierced by the vagina. 

[The flaps of skin should lie carefully fastened together with 
■titches berore the hody is movetl fnmi its po.sition.] 



2o2 



THE ABDOMINAt, WALL. 



DIB8ECTIOX ur THK AUUOIUNAL Wali,. 

The dissection of the Perinieum having lieen cojuijIoIctI, 
student should intxeed to examine the alxloiuinal wall, the conditio! 
of which will vary oonsidcmbly in dillerent subject*. In « 
subject the wall of the ubdumeu will be smooth and uniform, Imli 
a thin nuiscular (-ubject the prominences of the muscles will 
readily recognise<l. lu all bodies the luubilicus will be seen in I 
n>e<lian line about midway between the pubes ond the ensifoi 
cartilaj^e of the sternum, and nearly in a line with the highest ])oii 
of the iliac cu'st, and it shoulil lie noted whether tliere is any pn 
trusion at thin point, ci instituting an rj-oiniiliitlm or umbilicid hen 
The median line above the umbilicus will be found to l)e sbyLtl 
dcpress<'d, t'orrcsponding, as will be afterwanls seen, to the Un 
alha. Below the umbilicus is performed the o])eration of pance 
tesis or tapping the al>domen, and it should be noticeil thnt 
mesial fuiTow exists in this situation. 

On each side of the mciliun line and parallel to it, is the ptoo 
nence caused by the rectus alHlominis muscle, bounded exttrnu 
by the linta urmilunant, and occusioually the mai-kitigA in ih 
muscle known na the lima' imwn'eram can be seen through the sk 
Imuiediately above the ptd>es und close to the median line is 
sionally seen the prominence of the pynimidalis muscle ou 
side. The puliic crest and spine will be recognised with the fir 
and FouiHirl't litjumnit , attacheil tu the latter, will W followed .ilu 
the fold of the groin to the anterior superior spinous jn-ocess of 
ilium. On the sides of the lower jiart of the thonuc, the int( 
digifutions of the obliquus extenius with the serratus magnus ' 
be seen through the .skin, in a well-develoixul subject, anil a lata 
siihrostal fos^tte indicates the upper end of the linea semiluiu 
Below, llie iliac crest will be found curving backwards 
ujiwarils from the anterior 8H]>eriov spine, anil a tubercular 
miuence is felt a little in front of its midpoint butweeu it« I 
extremities. 

The condition of the ab<loinin]d rings and inguinal canal shoij 
bo carefidly cxauiined bei'ure the skin is removed. If the sp 
cord he traced up from the testis, it nuiy be felt to disappear tliroa 
an opening known as the external abdominal ring, and even in 
perfectly well formed sidiject the fore-finger can be parsed into 
ring with liderable facility, if pushed up from below, carrying 
scrotum Ijcfore it. In a subject with a tendency to hernia, 
tijif;tr am he carried along the \T»<i,tt\na.\ ca'Qa.V \« U\e inb 




NKUVIC^ Ol- AMDOSIINAL WALL. 



' if a ni[itur«? iiit\iu)ly txi"t», mii.v W' |«v«»vil into the 
. piijJunj; tlif lofjw kWIii licfoir it. If luiv tnuiimr 
imIuui •lu/iild liniijifii t<i lif ])r(:.Heul, it should Iw larefiilly 
l and itii nature diiigiKMcil, with a vit-w tu cuiiHrmutiuu by 
> lit exnniinatiiiii. i 

,■• fejnalo, llio alnlotuiiial ring in \i.stmlly "f unmll mif, and " 
lljr too conlracUMi to admit tin? tinK«'fi but may bi> rnlnrgwl 
• h«mia. The jirojeclion aliove the iiulwi", wlitch in covered with 
liair aiid known a" the mom I'enrrit, bdue niniply to a di'Velopn»i?nt 
uf fat in the nujHTlicinl foAcia at tliiit point. Thv »kin uf thi- uli<lonirn 
uf vodiicn whu havr Ixirne ehil<lrcn is niarkrd liy numcMuii uniall 
vbitc »cans the n-»iilt of it* i>vii-ili>lcn»iim durin^; jirrjjniini'y. 
Pr^>u«>io^ and ludpatiun "hinild be ciinfully practised, in onler 
^ !■ out the liniito of thi- [iriucipal or^unK of the ainlonirn 
Aif. dt.'t^Ttion iii bfj;un. 'I'hf pn;»i-nce of fluid in ihi' Jiurito- 
ncal cjivity may !« n»r<Tt«inird by the jirrHliiotiun of lluctuatlull, 
IxHween the IwiniU A]iplinl on i)p)Hisit«! t.idri< of the alxlomcn. 

[In order t'> diswct the abduminal M-all, it u nvcMmiTV to distend 

the ttUlomen fully with uir. To do thin, a narrow knile »hiiiihl )i« 

Uinisl tlimiiudi the umbilicus into the jieritoneul c.ivity. and a 

' ' ' ' 1 A circular inciiiou hIiouIiI prevloimly 

round the iniibilicu», and a vieie of 

_wn ii» '.1.1 i!,i n.iiii.i luf lil..w]M])c in the ;>roovv cut in liie iikin. 

H^Tlicn the aUlomrit lia« U-cn fully disteuiinl, the blowpipe iii to Ik) 

Hk^^wn, and llie opiiiiu;; laiefuUy Be<:ure<l. 

^^^^ntnciiion i" lo l>e ijirried from the ennil'orm larlilaj^e to the 

^^^■^\..;<Iiii . ill,- niiil.ni, .,-. ;.Tid another alon^ the erent of the 

^^^^Bi. lor Hpitie of till' iliiiiii hori/..intally 

mHH II Ill-lit at ri^dit Ali),de>i. A tliiiil at 

\he level at the ensitonn r'arlilaj^'e in to ivnch well back to the 

luiDH. The »kin u then t.i lie reflected from the median lino by 

llttwe Inciniona.] J 

^■n'hc Baperflcial Fascia in thif re;{ion renemldes that tlirou<,'hout 
^^p Ixoly, but {h Koiiu'lime!) much loaded with fat ; it U to be riv 
^Hkled by the ^ame incigionii as the i«kin, aiul in doing thiM thore 
^^n lie founil in it the culaumjus nerv(». 

^■Tbc Cutaneous Nerves (Kig. 1 1 H) eon>«i.st of two itet*, anterior 
^H^ latrnil. The unUrior nnrx-en, which are Very Hmall, will b« 
^Bnd in two rows one clottr to the linea alba, and the other piercing 
^^m t«ltdon of the L'X(«nial obliijUu two inche<ifrom the median line ; 
^^B Utieritl braiK'hwi will be found of greater length, running along 
^^■Abr- Hume muHcle and also giving a few xmall tuiga J 

^^^Hk: ; seU aie ilcrircd from tiii> »ev eu lower dorsal lipVniM 



254 



THE ABDOMINAIi WALL. 

Fi(r. 118. 




Tig. 1 18. — The ncrrei of the abdommnl 

1. Poctoralu major (cut). 

2. Serrmtiu macnu*. 

3. Latusimut dorm. 

4. IntercuAta] muiiclcs. 

5. Rct'tuii ulxloniitiirt. 

6. 8ertinii ufobliquua cxtcmut. 

7. I.llilii|uu> intrmui. 

8. TmnftvrrwiliK abdominlB. 

9. 9. Xinth liorsal inTve. 

10, 10. Tenth (lonml iiirTe. 

11, H. Klcrrnth diinjil nurvi". 

12, 12. Tirei/tii duraal ncrrv. 



wall (from Uiiachfeld and LcnoIU)- ; 

13. Lateral cutnDiK>ut branch a( I 

lumbar (ilio-hrp<igiuitrio}i 

14. Anterior culaneuua bninoh of i 

hvfiogaitric. 
1/!. Anterior cutoneoua branch of ilw* 
inruinal. 

16. Ilio-hypogaatric and ilio-in 

nerrca. 

17. Latrral cutancoua branch 

leoond interMwIal nerrc. 

18. Lateral cutoneoua branch «f i 

VtKxiaViti uanre. 




VE8SEI-S AND NERVES OF THE GROIN, 255 

lerves. About two inches Iwliiml the anterior «pine of the ilium 
ind half an inch above the crest will lie found the lateral cutaneous 
bnmch of the /<w( dortal nerve, and cbwu upon the crcxt of the bone, a 
little posterior to the preceding nen'e, will \h! ocen the iliue branch 
1^ the ilio-hypoga»trie nerve (lot lumbar), l>olh uf them goin;; to the 
buttock (13), while the hypogasfrir Itntnch of the latter nerve may be 
traced in the hypogastric region over the lowi-r i>art of the rectus. 

Accompanying the nerves will be found (in a well injected iKxly 
only) small branches of arteries derived from the intercoxtiil, 
istemal mammary, and epigastric arteries. 

[The external oblique muscle is to be cleaned, the (li^ih-ctor begin- 
ning from below on the right side, nnd from above «n tlie left, and 
taking care not to remove its tendon near the median line by 
mittake. The interdigitations with the sermtUH magnus and 
latisaimus doni are to be carefully detine<l.] 

The Obliqnus Xxtemua (Fig. U!), 12) has its wjiprr iittach- 
ment * from the outer surfaces of the bony portions nf the eight 
lower ribs, and from the intercostal fuscia between the bone.<i, and 
interdigitates with the serratun nmgntiH by four or live i>oint.i above, 
and with the latissimus doni by three or four points Ixdow. Its 
fibres pass downwards to the middle line and ])elvis (p. ^r>7). 

[In order to see the whole of the insertion nf this nmsi-le, it will 
be necessary to continue the diHsection by rutlecting the triangle of 
dun left upon the groin.] 

The Suparfloial Faaoia of the Oroin (Fig. 120) is divisible 
into two layers — superficial and deep. 

The mperfitial layer of mperfirial fatfia (11) n^senibles that foimd 
elsewhere, but the Htep layer (b) (Scaqm's fa.s«:in) is inor>! meni- 
branons. It is direct^ continuous with the deep layer of the super- 
ficial fascia in the perinaium (p. 236), o])]iosite the upper limit of 
the attachment of tlie genitals, and is attached linnly to the 
bscia lata of the thigh below I'ou]Ntii's ligament, thus ]>i-(-vunting 
any urine which may have )ie«>ii infiltrated into the tissues from 
pairing down the thigh. 

Saperfloial Veaaels and Norves (Fig. 12i)). — Between the 
layers of superficial fascia will be found throe small branches of 
the femoral artery, with their accomi>anying veins. 

The mperfieial eireumflex tViac (d) runs outwanls ab(Mit the lirvel 

* This is frequantly termnl the * origin,' but tho peWii: attarhmcnt ia mthcr 
to be regarded as the more fixed point for the action of the muscle under otJi\- 



* 



256 



THE ABDOMINAL WALL. 



of Pouport'g ligament to thu anterior superior spine ; the < 
epifKUlric (<) runs uiiwaixls for a uliort ilistimco nit tin: aUlo 
Willi; and the mperior external pudic(/) nins over the «p 

Fif. 119. 







cord to the scrotum. The veins corresponding to tht*e arteries 
the sajihenous vein as it opens into the femoral. Uimn, or a 1 



tig. 119. — HuMsles of the anterior luipeet of the trunk (from WUmd) ; 
left nide of the bo<ly the superficial Uyer la seen, on thu right the deeper 1 



1. I'eotoraliii major. 

2. Iteltoid. 

5. Anteriiir border of the iHtimimuB 

dorsi. 
4. Si'mituii magnus. 

6. 8uli(')ariii8, rif,'lit iddo. 
6. PectoniUii minor. 



7. C'oniPo-brachinlU. 

8. Upper part of tho biiep«, ahi 

it* two brod*. 
0. Conii'oitI prtKrr*^ of tbd wnpi_ 
10. Scn'Titiii* iiiit^iiii^, ri^ht tide. 
U. Extumiil iutcro.vitul uiumdii 




THE OBLIQUII8 EXTERNU8. 



2.57 



r, Poiipiirt's li^ment will be found two or three gknJg, which 
wcrive the lymphatics from the penis and scrotLiin, and the parts 
•nand the aniu. 
,, The tenilon of the obliquiu extemus being exp(^e<I, a nerve will 

KunJ piercing it ab.iut two inches above the pulK-g — tha 
uirie brttndt of tin: Uio-hyimgaetric from the l;<t hitnbar ; and 
tBwther niiiy be seen issuing fmrn the cxtvnml alH.loiiiinal riii^' upon 
tbe ipvnnatic conl — the ilio-iiiijitituil (n), also from the 1st lumbar 
'i\ 120). The furmer is dinlriliutfd to tlie skin abiive tiie pubef, 
Ike Utter to thnt of the scrotum and penis or labivim, according to 
tlttiei, and to the inner side of the upper jmrt of tiie thigh. 

Iiow«r Attachment of ObUquus Bxternus (Fig. 119). — 
I l)T<i the iinterinr half of the outer lip of the crc,'<t of the ilium ; 
PoapAit's li;^iment succeeding this att.vhmeut is merely the thickened 
I'jrer Ijunler of the aponeurosis of the external oblinue, reacliing 
the anterior superior <ipine of the ilium to the spine of the 
ttl)is, and receiWng the attachment of the falciform proce.ss of 
Is fmm the fascia hit-ii of the thigh. (2) The pubic s[)ine and 
i of the same side, the symphysis, the pubiL'. crest of the opposite 
a small portion of the ilio-pectineid line beyond. The 
iCKasing the median line, often very ditlicult to demonstrate, 
with those of the opposite muscle, and so form a mesial 
filar area of thickened aponeurosis — the " triangular faiJcia." 
riiuiRular bond of strong fibres runs from the ituicr extremity of 
k's Ligament to the innermost part of the ilio-pectineal line 
me .«ide imineiliately int<irnal to the femoral sheath. This 
own as Gimbeniat's ligament, and will be met with in the 
,,<li*ction of femoral hernia, (a) To the whole length of the 
u\ line fr<jm the ensiform cartilage to the synipliysis pubig, 
hng with the aixineurosis of the intermd oblicjue. Tlie poa- 
free border of the muscle between the ribs and ilium is 
Uy separated from the anterior free border of the lali.ssimus 
1 by a triangular interval the " Irianyle of Petit," the base of 



^~ Extcraal oblique. 
U> III aponciiroBU ; the median lino 
lo the right of thi« number is 
the Unea alba ; the curved bne 
tftit* Irft. the linca itcmilunariH: 
ttte trunsriTM line« ubovu tind 
Wlovr the number, the Uneuj 
irtniTt-nsG. 
ku|art'a Uxument. 

al alKlominnl ring, 
muiolc of the right lido 
hi into view by the re- 



moval of the antfrior acgnient 
of it* aheutli ; •pusterior seg- 
ment of its sbenth with the 
dirided e<igo of the iiuterior 
segment, 

17. Pvmniidalis mnacle. 

18. Internal oblique. 

lU. Coni'iined tendon of the internal 
ohliciue and tninsversalis. 

20. Tho lower i-nn"ed border of the 
inleriuil oblique mutcie. 




,HK ABPOMl^XL V,AU.. 



■P THE ABDOMi _^^^_^^^ 

PSS ^ and the tt^or by 

milWl «"«. ^"^ y.g_ 120., ^ 




. , l.vcr of t'»'i» ^"' 



„( the mgttin*' ■" 

•'a intcrcolun-narj vH 



THE OBLIQUUS INTERNUS. 



259 



tpermaiie fateia. This mnst be removed to expose the 

InnT ring. 

he External Abdominal Ring (Fi<;. 1 2ii, f) is merely a cleft in 

lexternal uliliciue li-ndon, pliiced (iblienifly iniinediatcly above ami 

I the outer siile of the jmbic spine. In the healthy snbject it 

an^ilar with the base downwarda and inwards at the pubic crest, 

[ is about an inch in leiiglli and half an inc^h across. The tendinous 

limitbig it above and below have been named the pillnri or 

I of the ring. It will be obsen-ed that the outer pillar is flat 

I triangular at the npper part, but becomes round and thick below, 

*re it is attached to the pubic spine and corresponds to the inner 

emity of Poupart's ligament; whilst the intenml pillar attached to 

! pubic crest is flat and continuous with the rest of the tendon. At 

lil^r part of the ring tuny be seen some curved fibres running 

ttansverse direction and calie<l the uitercohimnar fibres, the con- 

of which forms the intcrcoluninar or external spermatic 

, and is prolonged as a covering of the con! ami testicle. It 

Tild be noticed that the spermatic cord does not lie in the centre 

I the ring, but upon the outer pillar or Poupart's ligament, which 

■ ■lightly drawn down by the weight of the testis. 

' [The exfemnl oblique i.4 to be reflected by cutting, both vertically 

"' horizontally, through its muscular (ibres where ibey join the 

•idoD, and by detaching them Iroiii the ribs immediately }>tdow 

"^ origin. The greater part of the mtifcle can then be turned 

tow&nis the loin, and the corresponding tendon may be dis- 

np 88 far as possible towanis the median line. The handle 

f the knife should l>e passed under the triangular portion of tendon 

left in the groin, after which the tendon may be readily divided by a 

tical incision, pjirallel to anil as near the median line as [losaible, 

rellecteil towanis the thigh without endangering the subjacent 

When this is done, it will be found that the tendinous fibref 

De side decussate or interlace with those of the other immeiliately 

the pubes in the manner deseribed. Tlie internal oblitjue 

tie will then be exposed, ami will be most readily cleaned bv 

_ nniug at the lower border of the muscle on the right side, and 

it the upper border on the left side of the subject. Near Poujiart's 

hgament, a little more of the ilio-hypoga.stric and ilio-inguinal 

nenres will be aeen.] 

The ObliquuB Intemua (Fig. 119, ij>. — Tlie fibres of this 
tnusde tiike a direction opposite to those of the obliquiia extemus. 
Tie origin i.H from the posterior tendon of the transversalis 
muscle (the so called " fa.«cia luiriborum " or " lumbar aponeurosis "), 
from the anterior two-thinls of the crest of tlie ilium, and the outer 
! of Poupart'* ligament. The npper fibres jiass to V>e in(«rt«d 

s 2 




200 



THE ABDOMINAL WALL. 



into tlie lowur iiiargiiis of tlio ajrtilages of the last fonr nS 
where they fall into u line with those of the iutcmul intrrc" 
muscles. Below this the muscle is inserted into tlje xijihoiJ uiipen- 
dix, and into the nicHiol line by an upuneiirosiig, which !<|)lit> to 
euclo»: the rectus in its upper two-thirds and passes in front of tJit 
muscle helow (see ji. 270) ; while the lower librts, becoming 
1,'nuiually more and more horizontal in their course to the iniiUI« 
line, in tlie end arch downwards to l.e ituerted into the jiubic cntt, 

and into the ilio-pectineal ljn« 



Ki(t. 121 



behind the attachment of Gnu- 
beniut's li(j;aineut, Mending with 
a part of the attachment uf tlit 
liansversalis to form the foi>- 
iiiiud tendcrn. 

In the male suliject, gome pa)* 
muscular libres will be found li 
be continuous witli the lower 
border of the internal oUiqur, 
and to descend upon the spc^ 
matic cord and testicle. Thex 
form the crcmaDttr. 

The Cremaater (Fig. 120. 
h) consists of a series of tliin 
muscular loops unite<l by delicott: 
fascial tissue, spread over the 
Dpermutic cord and upper portuf 
the testicle. It is altached trfer- 
nail)/ to the inner part of Vuu- 
part's ligament, where it is con- 
tinuous with the origin of thf 
internal oblique, and intrmnl'tf 
to tlie spine and crest uf the 
]>ube3. This musculu-fiiacijtl 
lumina constitutes one of tlic 
investments of the cord atui 
testicle, and as it separates the 
fascia spermutica externa (intercolumnor fascia) from the faoriu 
spermaticji interna (infundibulifonu process of fascia tnmsvi' 
it might be termed tlie fascia spermatica media. The crem ■ 
tupplted by the genital branch of the genito-cruxal nerve. 




Figi. 121, 122, 123. — Diagrams to iUustrote the lU'w-cnt of tlie testis and Um 
formation of tlic tunica. Vttgina\is (iVtivtin V>^ J.'t. V>Ti'sY 



DESCKNT OF THE TESTIS. 



261 



Fo explain tlif fonnation of thi* maxclo it will ho necMMry to 

ti> Uip enrly otagc of fuet«l life, wlu-n the testis wnn sitnati.fl 

aiti ibo alMldimn ainl iiiiiiK-JiiUely Ih'Ihw the ki"llu-y. 

About till- xcviiith liioiilh of fu'Uil lifti lh»' tf^tiH j)ai>'».« though 

tli«- irilrmul alKiuuiiual riiis, "titl I'y iho L'i;,'lith mouth rotu-heH ihii 

.a pi-oci'-w of ]>erit<iiii-iim (proee^tut i-aijinatu) iiieceding it. 

;.iil filiR'i o! the civmnstt-r wouUl njipnir to )«• lihrv") of the 

lUc drawn <iown by the tcntioli: in it* dcsrcnt. 

„ til Curling, n muK'ulftr hand, oonnixting of three »et« of 

llbrta and ciiltcd the ytilirmaniimn lulu, paweil from the j>ul»« to 

the testis, aiul it* divixinun hu<l tlie following iitluchnu-nt8 — orii; to 

the bnttoD) of lh« itcrotum, iind one mi each Ride of the oxt«m«l 

Fig. 123. 





ni&nl ring, to PouimrlV ligament and the ercst of the jmW 
1 >. By the nclion of theep bunds the tenticle wili drawn 
fur ue the exteniul ubdoniinul rin|j[, but it in obvious that 
wImb It hail luu'lietl this point the Lttrrul baiid-i muxt have bocoMtu 
liadxaiilal, and thiiD have lo»t all ]H;wer of traction ; and the further 
pnigrcM of the te»liM drj>cnded therefore ujiou the miildle band, 
i»V;.l. ...i.iinueil to draw the ghiud to the bottom of the Borotum 
The elfect of llli» was to utretch the lateral bands 
I !'• liic pubcs on eadiside, nnd thmi they were drawn down 
■i« cord, in which they are probably represented in llie 
' uie unxtriped nitiscuhu fiuciculi called by Henle the 
reina*t4-r." The rxtenial crvma>>ter 18 formed by the 
I luwci iiljt^ of the iatcmal obliiiiic, wbkh were curried dowjv w\t,\i 



262 



TUE AUUOMINAL WALL 



the testicle in its progress (Fig. 123). It must W udded, howev 
that more recent ulieervations render it ilnulitful if the descent I 
the testis ia actuully iicconijilished hy lliuse niettiis. 

[The internal oljlitjue is to lie divided by a vertical incision from 
the luxt rib lo the middle uf the crest of the ilium, and this is lot* 
carried nlong the erect and Pnvijinrt's lif,'iinient to nenr the lo»n 
bonier of the muscle. The muhcular tibres must l>e carefully iJiMii") 
until ucellnlur interval i» reached, in which, near the crista ilii, vill t« 
found the branches of un arlejy (deep circuiuHcx iliac). The muiclc 
is then to be turned luickwards anil forwards, cai-e being taken BM 
to injure the exposed neives or the suhjaceut transvensalia muscle] 

The Nerves (Fig. 1 1 8), iive or six in number, are bnneba 
of the lower dorsal nerves, uliich lun horizontally forwardi to 
]>ierce the rectus muscle and emerge on the front of the abdoOMlL 
At this stage they may be seen giving off their luteal cvtonww 
branches, which pierce the obliqtius intenms and extcmus at odok 
Close above the crista ilii niuy be found the ilio-hj'pogiistric tod 
ilio-inguinal bmnthes of the first lumbar nerve (i6), running down- 
wards ttiwards the jiubes. 

The Uio-hyiioijiistric has been seen to supply the skin above the 
]iubes, tlie itio-inyuinai that of the j>eniH and scrotum (labium ia 
ieniale) and inner side of the thigh. From one of thece o«rr«i 
usually the ilio-hypogostric, is giveji off an iliac branch M-hich ]>ieiw» 
the external obliijiie luid its fascia above the crest of the iliiwi, uid 
descends upon the onler side of the buttock to supply the integuiuest 
of that n-gion. The tti-dfih durMl ner\'e also sends im iliac cntiu- 
eouB twig to supply lui area of skin in front of the distribution a( 
the lost-nunied bmnch. 

The Transversalis Muscle (Fig. 124,6) has its oritjiu — 1 , from 
the inner surfaces of the cartilages of the lower six ribs, wheit it 
interdigitatcs ivith the diaphragm ; 2, by a strong a])oneurv6ii, 
which posteriorly ia divided into three lamina;, the anterior d 
which is attached to the intertransverse ligaments and anterior rat- 
faces of the trausvei«e processes; the middle to the tips of tht 
transverse prwesses ; and the posterior to the spinous pmrnrm oi 
suprasjdnaiis ligmnents of all the lumbar vertebra) (forming Un 
greater part of what is sometimes called the lumbar apvnt utvru ill 
faicitt ImiiUintm) (Fig. 130) ; 3, from the anterior two-third* of tk» 
inner lip of the crest of the ilium, and 4, from the outer thiH •< 
Poujiart's ligament. Its tendon tt{ nitrrtion ]<aE8e8tothe miii 
behinil the rectus, from the ensifurm cartilage to about the ji 
of the middle and lower tliirds of the muscle, and in front of U 
below this point as far as the pubes, being inseparably uiiite<l vitl 



INGUINAL HKRNIA, 



903 



the intcnml oblique ; luul into tlie puluc crest 
line, forming with th« int^rnnl oMiijiu! the ti>»- 
Aetum. — The tran8Vi?r»nli» in iwneiitinlly ii Cintnictilo 
It, ttnrl hiu little iir nu inlluun<.'« iipmi thu niovcmunt* 
Theolilii]\iiaiil tho 

in coiistrKtiin; th« Fl*. I**- 

hivity unil an* alxo 
ml llejcon of llie 
in of the vertebml 
all thmc muAclcf aiil 
partly by ilmwinj; 
fUft Ifr*"'"" nn<1 
^mtun- of th<- 
rou;{b the uieiiiuin 
They are hencu 
imotion (rxccfit 
i), of aUloniiiuU 
and of expimtion. 

i Inooikal Ukrxia. 

]jke b««t time for 

I couctirunl in 

To do tJiiii th<' 

llkl be rrstun-il u* 

tUi thrir iiatiiriil 

BtuiU-nt will 

fthe ext<Tn8l ftlKlo- 

^hc aiNTUiatic ciinl 

m'lll Im- i>e<-n to 

oj)i'niiig (the 

' fjwcin Imvin^ been 

Qovcd), and on tracing up the cortl by turning 

■tide in tlicir oriier, it will Iw found to diwippoar 




('Ti«v of thv tnnjvvrwlis Rbdomlnl* miucle (trvm WUixm). 



i>xtcnul ntiliqur. 
inlen-dntjil 

al inlen-ottals. 



ur(Mi«. 

truromit pitving 
}Sh of the rrctuM. 



9. T/)wcr p»rt of the left rertua, willi 
ttie upoiiourmu of tho intcniitl 
oliliqiie nitit Iraniivrntulis [mm- 
injr III frniit 



10. Ri^rlii r,-. 

11. I'oi, 
Vi. Til. 

lata. I 



\K-\e. 
■rit. 

' rnoriii iind{luteuii 
iini'iitml hjr faMjik 



2C4 



THE ABDOMINAL WALL. 



beneath tlit- i<linrp arcLed bolder of tlie timisversalis niuAcle. 
tisGUc boni'atli this muscle is the fascia triiimrertolit (Fig. 125, /j^ 
mid belwet-n tliis and the peritoneum, is the siibjivlitonrul liuofe 
Botli of thfpe layci-B are piolonged upon the cord and testicle a» a] 
infnndibnliforni sheath, and the inteniul urifice of the funnel, wbd 
artiticially defined with the knife, is called the internal abdonon 
riny. The prolongation of fascia transversalis itself is called tlir 
in/uiidibiilifonn or iyitmral tpennatii' faacin {¥\g. 125, »_), 

The Internal Abdominal Ring (Fig. 126), an artifld*! 
opening in the fuHciu tiimsveraalis, is placed midway betwetn ')•'■ 
symphysis pubis and the anterior superior iliac spine, and ;ii ' '. 
half an inch above Poupart's ligament, ijnniediat.ely outside the dee 
epignjitric ves-sels. The fascia is distinctly thickened al the low* 
and outer parts of the ring. 

The Inguinal Canal (Fig». ISO, 126) is an interapac« abog 
an inch and a half in length, transmitting the cord and extend 
from the internal to the external abdominal ring. 

In front it is bounded by 1, (in its whole length) the tenda 
of the external obli(jue ; 2, (in its outer third) the lowest 
of the musctdai' tibres of the internal oblique ; and 3, a smt 
portion of the cremaster. Btliind are — beg:inning neare*t 
intenial ring — 1, the fascia transversalis (for the whole length < 
the canid) ; 2, the conjoineil tendon (in its inner third) ; and i 
trjangidar fascia (if it exists') ; 3, the deep ejiigastTic vessels (iniB 
dialely to the inner side of the internal a)>doininal ring), bdov i 
the line of junction between Pouj)art'8 ligament and the low^ 
border' of the fascia transvei-salis. Ahove are the arched bonier 
the trans^'eraali.s muscle, and sometimes a stronger band of tibrw nl 
the fascia transversalis lunning over the vascular sheatlt (Fig. 131). 

Inguinal Hernia is of two kimls, oUiqiui and direct. Th 
obliijue passes through the internal abdominal ring, along tli 
inguinal canal and out of the external ring. The direct heinia break 
through or pushes before it the posterior wall of the inguinal ( 
at its inner pai't in a triangular space called Httstlhach't triang 
bounded by the deep epigastric artery, the rectus, and Poupoitl 
ligament ; and emerges at the external ring, thus taking a nin 
dirrd course than the oblique variety. 

The coverhiyf of each hemia will be best seen l>y tracing the 
from within outwards ; thus the oblique hernia would ]iush Imiot 
it (1) jiaiietal peiitoneum, forming the sac ; (2) subper 
fiisr.ia ; (3) in coming through tiie intcnud ring, fascia truusv 
or iid'undiliular fit-cia ; (4) in iiiuaing beneath the internal obliqui:, 
the creuiaster muscle, the fibres o{ vi\vwVi we urnVvA \»^ oiMm 



^ CfcMui^^J 



INfllTINAL HKRNIA. 



265 



are - known iw llie i-rettmiilcTir. fa«cia ; (SJ, 

tg fi'oi;. iiml riiip. Uie intt^rculumiinr or cxtonml 



¥-^>' ^' 




•permntir. fascin ; and finally (0) the tiijierttckl fujiciu und 
A dirtfi hernia lias precisely th« name covering;)} at) the oblique 



fif. 136 Oiiwction of the ingninal cuinl (from Wood). 

0. Ex'' I' (turned down). /. Kum-'U trauirertAlit. 

A, A. 1'. jii«. y. Triniigulni' (ldcIu. 

c. Trfci^vcruMii.-*, A. Creiuiuli-r. 

tf. CoDJaintd Undcm. [uj^ui'it. >. liifunilibuUr fuacui. 

r. Hrrioj tbdomittu irith Mlumlb 



26G 



THE ABDOMINAL WALL. 



forni, when it passes through the outer portion ot He 
triangle, but shouUl it force its way through llie inner part'^ 
triongle it woulil derive an additional lamina (superficial to tit 
fascia transversalis) from the conjoined tendon. It would not, how- 
ever, receive its cremasteric investment in either case nntil it enti 
the Bcrotuui. 

By dividing the fascia transversalis immediately to the ina 
side of the internal alidominal ring, there will be found the ie 
epigastric arterj', running with its vcnai coiuites in a line from 
middle of roii))nrt'B ligomtut towards the umbihc\is ; and 
varieties of inguinal hernia have been named extrniat or inti 



Fig. 126. 



Deep c^igaiitTic wierj-. 



Fascia tnuagrarsalis- 

Conjoinn} It-ndon 
Triiinfiiliir fascia 



Intemul obliqof. 




Cremiuter. 
Extenwl oblique. 



according to their rehition to this vessel. It is obvious that 
hernia, passing through the intenial ring must be external to th 
artery, ond hence obliijue hernia and external hernia are synonj 
mous terms. In the same way, direct hernia prolrxides throu^ 
tlie abdominal wall to the inner side of the epigastric artery i 
thus internal is the same as direct hernia. 

The anatomy of the parts concerned in hernia being fully con 
prchended, it will be readily seen that the direction in which fort 
is to be applied to return the protruded bowel into the abdomcu— 
coniniouly called the laxit — must ditfer in the two cases ; and the 
student should notice the ettect which the position of the body 



Fig. 126.— Diagram of the inguinal cnnal, ahowing its nnterior and p<Mtenor 
boundoi ies (dtuvrn Y)^ J . TC . Ora.^'^ .\ 





INGUINAL. UeilNIA. 



upon the tiMtuiM uc«r (Ik* |i>roin. Thux, with the 
extvn<i«<I ut full Ivtiglh, lite lowvr (mrt of the 
Iflc-mi terinf ; whilst if the tliifjli in tUxvA ui>on the 
nctol, and the bo<ty l>oweJ forwaril, the structures 
and would mora readily ulmit of the return of the 
. 

Itmia. — There are two TAriRtir* of nhliqiic inguinRl 
'pngmititl kemia ninl iufantiU or it»eyittil htrnia, the 
e)i re<iuire« oxiilaiiation. 

til thpue fully it will Iw neowsiiry to refer ogiiin 

of the teulU (p. ^61). Wheu thu lenticki is in 

t UoB the peritoneum nltiichfd to its DUrfuce, ami 

lent into the gcrntuni it acconlin^jly cjirries n fold of 

jprn with it, Ml that at firil n tn)K> extend' nlung 

)h of the inguinal canal (Pi^. 123). Ky a nnlitral 

tliu later ni'inlh'* of fa'tal life, however, an oljliteru- 

liou of tul>e within the o«nal t^ikeo place, and thui a 

nuul around the testi!i, which is calle<l the tunica 

I a mere ilimplu is left in the peritoneum at the 

Thtw in the onlinnrr condition of the jiiirti wlu-n a 

^ itB doc is ul>ove and quite dixtimU fr>>m the tunica 

187). 

I however, thi« obliteration dfxw not occur, and the 
b remaiuj* continu'>u>i with the |>erilonvum. In 
^ia devcenda at once into the tunica vaginalis and 
; with the testis, and l>eiiig the eon8c<[ueneu of a 
fl it is termed comjfnital liernui (Fig. 1 28). 
I Uirmeil fongenilnl hydroeelf the nniitontiail arrange- 
Imc, and the fluid run« from tliu jicritoncnl cavity 
ktn or in the revewe direction, according to the posi- 
enl. 

tttcytttd hernia exists whisn only u partial obliteration 
|1 tube ha« taken place, the tunica voxinalu) being 
I usual and extending upwards, towortls or into the 
Should a hernia descviid, it passes down behind 
t the tunica vaginalis, ami there ore then throe Inyere 
llimne in front of that covering the intestine, two 
gr tbe tunica vaginalis and one by the peritoneal >uic 

\pttratioii for Htraiigiilated Hemut. — In this operation 
reach and divide any tis'iue which i>re.'<«e9 upon the 
tats its return within tlie abdomen. An iuciAum \a 
«y ling, and tiie surgeon di.s-*ects caiefvvWy iVowu 



268 



THK ABDOMINAL WALL. 



thmiipb the several layci's (never ilislinotly recdj^nisjiblc in prartifl 
uiilil he reaches the iieritoneal sac, which is fonielinies kuuwii h 
its bluish appearance. The hic i.s then carelully opened nnU ill 
cuiitcnts inspected, and dealt with according U< tluir ci>li<lilii>l 
Pasgin;; the forelinger carefully inside the neck of the Sflc lie feels fd 
the 8lrictiire, which may jnii-silily be at the external rin;,' (wheieitf 
easily divided), or more jiroliahly within the in;;iiinal canal. Huvii 
dJFCovered it, he next parses the hernia-knife alunj; the linger, un<l 
using the dipt or a director as a giiiile, iniiinuutes the knife, lieb' 
ll«l, heneuth the titricture, and divides it by biinning tlio cdg 
upwards and pressing it u^-ainst the ti.ssuea with the tin^^er. 
The direction in which the siiperticial incision is made is of little 



Fip. 127. 



Tig. 128. 





conseijUence, but in the deeii incision the r.ile is to cut upvarJ* i 
a. little inwind*, im> as to be jiarallel to llie epigastiic artt-ry ; 
since a mii-take in the diagncsis between nn external and an iiitem 
heniia may occur, owing to llie parts becoming distorted and I 
abdominal rings drawn together in old-standing heniiie, an inciaid 
in idnioBt any otlier direction might lead to a wound of the artery. ' 
UiidindCvTt of Hrrnia. — Vai'ious operation.^ for tlie radical cure < 
hernia have lieen emjdoyed of late, the principle of tJl being 
isolate the sac as high as possible ami obliterate it by ligature ; n 
u.iually also to draw togutlier more or less completely the wall* of 1 
inguinal canal. The operation can be done either by a free iucisid 
exposing the external ring, the pillars of which may then be xtitch^ 
together, and by some operators the conjoined tendon ia also iuclud^ 

Fig. 127. — Diiipraiii of a vommon tcrntiil hcruin, showing the tvlstion of 
ue to the tunica vngiimlis testis (J. T. Ciniv). 

Fijc. 1'28. — ]>inj,'nini (if a congeuilul Uernin, the Bac being continuous witbt 
tuiiicii vaKinuliii testis (J. T. tiray). 

Fig. IJy.— l)iii;nT»' of I'll infuiilile hernia, showing the tunics vnginnli< pn 
JougeJ iu iroiit ol the sac (J. T. OrayV 




THE CORD AND PENIS, 26!) 

in the ftiUure. The older Mibcutaneous opcrationH of Wood and 
Wurtrer are now practically aban<IonefI. 

The Bpenuatlo Cord may now bo examincil, and will be found 
to consiitt of (1) the vai dtftren* or duct of tlie testicle, together 
with the deferential branch of the Hupcriur vosicul iirtery and the 
deferential veins with lymphatics ; (S) the spermatic artery with its 
complicated ])lexuH of veins and the testicular lyni]ihaticMi ; (3) the 
internal creuiaster, small ImuuU of im8tri]>ed muwular tibre, proluibly 
the relics of the lateral b:mdH of the gubernaculum tcitix ; (4) the 
obliterated processus vaginalis of the i>eritoneum ; (fi) Hul>-pcrito- 
neal connective tissue Murrounding all the structures named and I 
,soitt<;times bearing mortt or less fat in its meshes. 

^♦^J^je CoveringB of the Cord from within outwards are a* !. 

•'^Uows : — (1) infundibuliform fascia, from the fasi^ia tiimsversalis ;'»; 

ji^iC^) cremniituriti fascia with the sup])lying branch uf the gmito-cniral ^ 
nerve and the cremasteric artery from the def)i cpiga-tric ; (3) inter-' 
columnar fascia ; (4) superticial fascito and integument. These "?, 
various laniinie are for the most ]>art cu]ia1ilu of sulj^livixion into ; 
secondary layers, and hence it is always diflicult to identify the ' 
numerous planes that are encountered in dissection or o|H'nition. ' 
The cremaster may, however, l>e msule out by its muscular fasciculi.^ 
The vas deferens may reiulily 1h' felt through the roverings as a • 
hard cord, lying as a rule behind the other elements and esLsily 
■epatable from them. 

Tanloa Vaginalia Testis (Fig. 127). — By drawing the testicle 
out of the scrotum and making an incisinn over the iinterior pai-t of 
it, the tunica raginalit will be ojH^ned, and will \w seen to I'onsist of 
two parts, the tunica vaginalis jirnprin (vinceral lamina) u)u>n the 
testis, and the tunica rrflva or ]>art around (]>arietal laniinaV The 
tunica vaginidis propria adheres intimately tx) the subjacent 
tunica albuginca. 

The Fanis should now be examined, and the student may 
advantageously practise the operation of circumcision. It should 
be noticed tliat the skin assumes somewhat the aspect of mucous 
membrane at the margin of the fore-skin or pri-pm-i-, and that 
it retains this appearance as it covers the <//'(/m ;«'ii(x.- the true 
mucous membrane, however, terminates at the distal part of the 
urethra, before reaching the external orilicf or mtiitiin. I'.elnw the 
oriAce of the urethra will be found the fold calleil the frtniinu 
praputii, and around the base of the glans ]>enis is u circular ridge, 
the corona glandxi, u^ion which open a number of sebaceous glands, 
the glandHite otion/lfnr, that secrete the tniegnM prmfnilii. \u 



,„. «DOM.»^^ ■«"•'■■ 



P THE «DOM.»-- ^,,i.p»^;W 

". s.v»« j-jVbrft" '^•j:^,.„.te..i««^-'. .,,,1, ./ 

(Fig. 120, ^)- 




RECTUS ABDOMINIS. 



271 



[In many subjects immelUtely above the pubes, in front of the 
Betas and. enclosed in its sheath, will be found a little muscular 
Up, the pyramidalis. Both muscles are to be cleaned in the 
utectioix of their fibres.] 

The Pyramidalla (Fig. 1 19, 17) arite* from the crest of the pubes 
Blose to the median line, and passes up for about two inches to be 
inm-Ud into the linea alba. 

The Rsotos Abdominis (Fig. 119, 16) ariM$ from the pubic crest 
sod supra-pubic ligament, and by an interlacement from the front of 




the pabic bones and interpubic joint. The inner til>rc8 of origin 
are fleshy, the outer tendinous, but there is no division into two 
* heads.' It expands into a broad muscle, and is vuerted into 
the enufonu cartilage and into the anterior surface of the cartilages 
of the last three true ribs (5th, 6tb and 7th). 



Fig. 130.— Amngament of lumbar aponeuronii at level of third lumkur 
vertebra. 



1. Sacro-lmnboUt. 

2. Pmu magnns. 

3. Tiimriwiinni dom. 

4. QuMiitas Imnbonun. 
6. Latiiamiu doraL 



6. External obli<|ue. 

7. Internal oblique. 

8. Trantversalia. 

9. Ecctu8. 



272 



THE ABDOMINAL WALL, 



The Hneas tranivertai are tendinous intersectiona comsfjonding 1 
abdominal ri)is ; one is placed nearly opposite the utnlrilicoi, i 
second at the level of the ensiform cnrtilnge, a thinl Ijelwn 
these, aikI a fuurth in occasionally fouiul lieiwcen the utnhiliciu m 
the puljes. They seldom extend thruiiyh the whole of the Kiucull 
fibres and are distinct only in front, where they iujhcre finnly to ihtl 
shea til. 

The rectus is a powerful flexor of the lumbar vertebrar, inclinmi: 
the lliorax ujKjn the pelvis or vice versA. It acts as abtlor, ; 
eonifiressor mainly by increasing the resistance of the unt-i • 
alidoiuiual wall durin}^ the action of the other muscles of rii. 
wgion,* and it assists txpiration by drawing down the stemuin ami 
sternal extremitifs uf the rilps. 

The Deep Spigastric Artery (Fig. 125), with its venx 
comites, will be traced into the Imck of the rectus muscle, where the 
sheath is deficient, passing in front of the fold of Douglas. The 
muscle should be divided and the artery will be seen ruimiDg 
towards the stemuni, anastomosing with the lumbar, lower iol«M 
costal, and internal mauiniary arteries in its course. This anattiM 
mosis brings the external ilinc arteries into comuiunicution wiln 
the suliclavian und aorta, and comes into play after ligature of thll 
external or common iliocs, orin awes ofolwtructionof thede8cendiiii| 
aorta. 1 

The nerves piercing the rectus ore the terminations of the loweH 
intercostal nervcx, wliich pass through it und itt sheath to reaeV 
the surface near the middle line and supply the cutaneous uca 
between the linea alba and linen semilunaris. . 

The Fascia Transversalia L^ the inembmne lining tlie truiM 
versalis muscle, mid is continuous with the/nwio iliaca (cov^■ringtl^a 
iliacus and psoas muscles) ut the iliac crest and Pou]>ttrt's ligamentJ 
and with the diaphragmatic fascia at the line of origin of tliiq 
muscle. Opposite the point at which the external iliac vussels paM 
Ijenenth Poupart's ligament it gives a jirocess to strengthen ihel 
anterior wall of the femoral sheath, while the fascia iliaca posseil 
upon the iliivpsoos l>eueath the sheath luit witliout aiding itq 
formation. (The sheath itself is a continuation of the sub-]>eritoi)ecd| 
investment of the external iliac and other abdominal vessuUjI 
It is usually thin and transparent, and is sometimes difficult tM 
demonstrate on account of its intimate connexion with the KutJ 
peritoneal tissue. At the internal abdominal ring the ti in lui i iiiiIIm 

• If thi' nMnmen b« aunken the lino of the rectus prownt» a foi-wanl oraJ 
imrily, rtiid durini; contrflf tion tUo niusu-lo becomes more widelv aepuruted froifti 
Out »pine &ad will lieuco teud to reduuu tUe y>tcs«utu u^ou X.W \u£ia*c%. I 



CAVITY OF THE ABDOMEN. 278 

is prolonged over the cleJiients of tlie spermatic cord as the 
intondibulifonii fascia, in the manner descriWd (p. 2C9). 

Action of the Abdominal Muscles. — The actions of the 

»Wominal niiiscle« mav be snbiliviileil into two piiupr', locomotive anil 

coustrictive. As ortfuit^ of hcuniolMn the muscles iiuliiu' the thorax 

Jijion the j>elviji or the jiclvis upon the thorax in the antero-posttrior, 

UtcTtl, or oblique directions, mainly at the lumbar anil dorso- 

Imnbu articulations. Ak organs nf )ih<}om{)i(il constricti'iit tliey com- 

p<B the various organ.s in the abilomiiiojiel vie cavity, ami no aid in 

the expulsion of the contents of the ston.acli, bladdtr, intestines, 

aid uterus, and jwtholni^acally in the production of hernial pro- 

tnuion* ; while by their influence upm the vessels they play an 

important part in the circulation of this blooil and lymph. They 

ttorefiver assist in contracting the fiioracic c^wily in all expinitonj 

K^ P»rtly by pressiiif; the atxlouiiiml viscera into the hollow of 

the iliaphruj^u, partly by their direct jniwcr of drawing down the 

Btmum and ribs. The special actions uf tlie tnuisversalis and recti 

1; luve already Ijeen described 

The alxiominnl muBcles are gupjjlifd by the lower six intercostal 
Wve«, and by the ilio-hypognstric and ilio-inguinal branches of the 
4o*lainbarner>e (Fig. 118). 

[The ahdoniinal wall having been finished on both sides, the dis- 
K4(asahould cut throuf^h tiie reniitins uf the abdnniinal miii-clcs in 
1*0 ur tliree places until the peritoneum i.-. exposed, but without 
tHjariiiff the latter, in oixler to .xtudy the aii])eanince uf the mem- 
hrtne which forms the stu; of a hernia. They ."hould then open the 
•hdooen and dissect the viscera.] 



Cavitt of the Abdomen. 

[The alNlomen is to be opened by a transverse incision at the level 
"fthe umbilicus, and another cut is to be carried from the umbilicus 
to the sternum, a little to the left of the median line.] 

_^By holdini; up the lower portion of the abdominal wall Ixifore 
HSdiog it in the median line, and viewing it from 1>ehind, the 
Vncton will perceive through the perituueum tive cords taking a 
eoime towards the umbilicus (Fig. 131). The cetitriil cord is the 
oUitemted uiacbus (?«), those on em-h side of it are the idjliterated 
ilTpogiBtric arteries (t), and the most external corresjiond to the two 
epigutric arteries (b). The peritoneum is raiserl into distinct folds 
hy the obliterated hypogastric arteries, and in the membrane external 
to the epigastric artery on each side, a little above the miildle of 
E^onport''* ligament, may be seen a small dimple (occosvotiaWY \lkb 

1 




274 




CAVITY OF THE ABDOMEN. 



orifice of a minute tube, the procetmu ragiiialit), marking the 
of the intenial abdominal ring. Tlie fiballow }>eritoiivid d' 
bouiuled by tlie«e cordg nn* called inyuinal pouches, the middit pt 
lying between the epigastric niiJ hypogastric foldo, the inttmal. 
tween the hypogoBtric fold and the urachus, and the crtrmal oai 
outer side of the epigastric fiihl. The term " HrjKlbach'i I 
anyle " (d) has been ap]ilied to the triangular space bounded 




I 



Tig. 131. — IHantinii of thi' Inwrr part of Ihr iibdntAinal wall from 
peritoneum having bccu icmovcil (from Wood). 

a. External iliiir artery, /. FiiK'in trantvenalii. 

i. Ejiiputric artery. y. Va> ilefercaii. 

c. Boraer of the p'oiteriar part nf the A. Siwmiatie tcmcU. 

•heath of the rectui (fold of i. QDlitrrated hj-pngnitrirj 

Dougliii). i. l.yiii|ihaliR> in I'runil i 

(/. ConjoiniKl tondon in the triangle of /. Inlrnxil nbduminal rin| 

Hewelbach. m. l'nulm«. 

r. roaterior surface of rcctua. n. Bladder. 



CAVtTY OP THE ABOOMEM. 



275 



Uie boixliT of the rt'ctiiit iiitcrimlly, (he «>]ii),-n>ttric artery oxtertmlly^ 
•ntl l'<.ij|uirt'H li;,';ime:it Ulow, ami it in throiijjU thu lliul dircotJ 
'"'■ - it* way. It it iiuli<liviilt.-(l into two pm-ts by 

*'• j.i>tric artery, whiih, like the cpign*trii' iirtcry, 

i» ollcu *u(.|RiiUii Uy a iliftiiict fold of puritoiu-iiiii. The /old nf 
ThuyloB ((), or N]iar|i lowur iiiarKin of thi; jxwtcrior »henth of the 
tBcliu, wiU be re«<1kly iwroeircd through the p«ritoneuin. 

Fi)f. 132. 




Fig. 132.— M«<liiiii M^ittal (dvtion of ■bdoimm (nfter Braune). For tower 
argmi-ut Mie Polrii. 



1. T<^tli ilnraal TrHrbra. 

2. ': ■ 

•U{Mriur iu»«nl«ric rt> 
A. Aortii. 
8. "timatramr duoJaoum. 



7. Siirmotil tlejcure. 

8. Kt^ctum. 

9. Uver. 
"iiillT 10. (itiiiimfh. 

». 11. TninnTcne colon. 

12. Jpjiinimi. 
U, 14. Ileum. 



T 2 




276 



CAVITY OF THE ABDOMEX. 



[By dividing the lower portion of the alKlomiiial wall in th? I 
line, it can be refiecte<l on each side, and tlu- alHlumiiiu) c'Jiit''nU will 
be exiKs»-(l.] 

Abdominal Cavity. — The parts first seen on openinc tht ih 
men iiri: the stomiuh und porliona of the right and left ' 
liver ; und the gidl-li!a<lder if distended generally lies 
costal marj^n where thus is joined by the liiiea M^uiiluiians ; 
it rautit lie reniem1>ered that the liver is higher in the rrxunib 
than in the erect position, and that in the child the organ i« 
and the right lobe extends nearly or quite to the median linn 
front. The great oiucntum passing down from the stonnarh i 
ceals the rest of the intestines. Should, however, the • i H 

turned up, an often happens, the moss of the small in' III 

be visible, and immediately below the stomach the tran- 
Tlie OBcenJing colon and sigmoid flexure will be more i.^ 
on each side, according to the amount of their distension. 1 he unxum 
may usually lie seen a little iuteninl to the anterior siijveriur ilia 
cpine, a:id a portion of the sigmoid tlexure at the correiiioailiBj; 
point on the opposite side. A very much distended bladder, or tlit 
pregnant uterus, would also be apjjarent. 

The princijNil ttriidnres cat hy tht median nujittal platte art u 
follows (Fig. 132) :— 

(1) Liver, left lobe and lobua Spigelii ; (2) stoinaih, ru-u 
pyhirus ; (3) transverse colon; (4) small intestines, iml > ^ '. 
transverse duitdenum ; (5) jjancreas, neck and lower extensiou ol 
head ; (6) i>elvic sigmoid flexure and rectum ; (7) bladder ; (S| 
uterus in women ; (9) aorta with deliac axis and superior mcsiai- 
terio artery ; (10) splenic, left reual and left common iliac vcir:-- , 
(11) greater and lesser omentum and mesentery. It is il. 
that these relations should be studietl as far as jiossilile beli i ' 
parts are much disturbed. 

Regions of the Abdomen. — For ctrnvenienw of de^ciipticB 
the alKlcinieri is divideil into nine regions, by four iiuuginary plaoea, 
two longitudinal and two transverse. Of these regions three at 
median, and are called res])ectively epigastric, umbilical, and bT|io- 
gastric, in their order from above downwanU, and the I'eniniuiDg ux 
lie three on each side, and are named hypochondriac, luiuboi-, aaii 
iliac or inguinal. So fur all anatomi.'^ts have been ogreeil for vmm 
centuries, but unfortunately even at the jiresent day there is n<< uni- 
versally accepted rule for the position of the subdividinLr 
and conse<iuenlly the epigastric, lumbar, or other region of d 
iMxik may differ veiy wiilely in .limensions from that descrilieil is 
anoUier. Under these ciicumalancea \\,\s (5iO\i\AS.T3iV'«\uA\\v:T\V'«<ji 




CAVITY iiK THE ABDOMES, 



277 



lie !«'ttfi to Ahaoilon altogetlier the U8« of terms wklcU Luve no 
iii>c nicAiiiiig. 

bi< following scheme i^f lU-liiiiitution is perhnpa tlie iiiuat cou- 
lieiit. The ujiper irtmtrtnt plane corrcs{)oniU to the lowcat 
|)Oint of tile cogtAl iiimxin on each side, the lower plant to the 
anttfriur sajK-rior ilinc «]iine«. The inter«t-ctin)( loniptudimil piina 
ixv drawn ii|rwiiid8, one on caiU side, from tho pubic »j.iin*< ulong 
I outer Ixink-r i>f the r«-rtu«. The jHisition of tin; vigci-ni in ivlii- 
t/i till' rvgionn m> mai'ki«l out niny lio funuulutvd iis follows : 

;it till' iijiiK.'T piirt, thi- /I'lyr will be found to oocujiy the 
londriuc, till- i'iiif,'!islri<:, lunl a aniiill ]mrt of the Lift 
Tiy]x>tl»i'Ui|ii.ic n-j^ono, iind nuiy clrscund into tho \i]ipcr part of the 
left luiiibiir n^'inn ; jinsaing to it fnun ihi; unibilicuM will \w seen 
tlie oblitcnit*-d iiiuliilii'A] vt-in. It* anterior luiir^'in is sharp ; itt 
jwr " Nurfuct", which um,v be diviiled into unlerior. nuiMTJur iiiul 
Utcpil faces, corrc»)>ondi> to the diaphritgiu ami U) the alMlo- 
I wull in tlie Kub-coslal iiii);!e ; its viaceral or " lower " iinrfaca 
backwBtUs at well aa downwnrjn, and it in contuut with the 
Riarh, the cuuinienceuient of the duodenuni, the hepatic Hexuro 
^ uf the iidon iind the rinht kidney ; and its i>o»terior nurfitce will bo 
• n to Ik; adupted tii th<' crura of the diii]>hru)^'ni, and to 
■ It, vena C41VB, iitid the right HUprureuul ciipiule. The 
tiid <•! the thomcic uortn lien behind the cnint of the dia- 
ifUi, opixwite llu- interval lietween the venu cava niul U'tiopha^u. 
ittimitA-h will lie Keen in the i-pigiistric region, with its greater 
idc siu' ii-(uJiinj|; into the jtlt hyi>i>ohondriuin, 15y drawing this 
out from Ijeneath the ribs, the upleeu will In- found attitched to 
nl is «<>mctinie8 Uiund firmly to the diaphnigin by old iutlani- 
ory mlhexioiMi. Tracing the stomach to the right side it will 
ifutind to reach alnioi<t to the gnll-bludder, terminating in the 
Icliuin, the line of demarcation being marked by a thickened 
of annular tibrcB, the jiyluric sjdiincter. In front of the Htomach 
Ijc diaphragm, the aUloniinal wall, and the liver ; behind it 
afterwards be seen the paiicreaa, the crura of the diaphragm, 
Borta and vena cava, and the left kidney and capxule. The 
inm can be followed for a "horl distance only at preneut. By 
up the great omentum, the transverse cohm will be e.\|)OHud 
Ing Uie umbilical region, and continumis on the right kide with 
ejutic llexure (right hypochondriac region) and lutcending 
and on the left with tlic f-plenic flexure (left hypochondriac 
I) and doscending colon, which ahoulil be traceil out, Occupy- 
lieUy th« hy{H)ga8tric, but extcmling into all the middle aud 
• r*%'i»nti, ant the cuih of tlw miurlt inltxtine, two-fifths ot wUvtbi 



278 



CAVITY OF THE ABDOMEN. 



cimstitutc the jejunum, and the remainder the ileum ; the latt^-r i 
be found to end in the large intestine in the ri^ht iliac fossa, whiS 
the coniiueiicement of the colon (caput atcum coli, or ca<um) will I 
recogniseil by its little iippendoge, the aiqvniiix venni/ormu. In I 
left iliiic foBsa will be seen the tortUDUs portion of the large intvstiii 
calk'd the inffnwul Jlcxure, whieli niny be traced intu the jielvis to f 
termination in the rectum. The inguinal canals lie in the it 
regions. 

TABLE OF ABDOMINAL CONTENTS. 



Jtislil Hupochon. £,,iga,tric It^ion. I ^•'f'H'^^ 

driar Jtci/ton. ' ■' ' JSC^IM. 

Part of right lobe Stomach (with both orificen), left I StomniU (mn 

of liver, part of p»ll lobe and a part of right lobe of cn(i),9plcrniuidt 

bladder and hepatic liver, part of gull bladder, Ist and of panrieuj, «j)lei 

flexurcof c<jloii,rif;lit part of Sod part* of duodenum, ab- \ lle.xun; of colon. I 

supra-renal (Mipcule, douiinnl aurta, vena cava, Borni-lunar snpra-renul i-ap«d 

and part of right ganglia, receptoculum ch)'li, veuu part of lett kiili 

kidue} . a/ygoK, puncreaa, upper and inner | and a purt of 
part of spleen, parts of kidneys, and ' left lobe of ibe li»i 
both supra-renal capsules. i 

Itight Lmnbar rmbilicol Reg,u„. \ Ltft Lumbar 

Region. Ivgxm. 

Aaeending C4>Ion Great omentum, transverse colon, I>i*sviniding C0I4 

itiieaseuni in some '2nd (lower )uirt} and 3rd portion of smull interline,) 

small intcs- duodenum, part of right kidney and of sigmoid tiexu 

'tine, part of right srinietinicsiiart of lrft,ureter!>, tmall sonieiimr* jiait 

kidney and some- intcittinc, bilurcation of aorta, for- left kidnry. 

times' part of right mation ol veuu cava. | 
lobe of liver. | 



Right Jnj/uiHal 
Jtcgiim. 

CiBcum coli, with 
vermiform appendix 
and part of ileum 
in most coses. In- 
guinal oansl. 



Iff I /«;/", 
Jttfg\0>t. 

Part nf ?iin,..ii 
tiexurc and >nt;iil lo 
leitiiieo. Injiuusi 
canal. 



lljipogatlfit Region. 

Small intoatines, ntpr\i!<, upper 
part of bladder in distensiuu and in 
youiig children, and the pregnant 
utenis. These lie above the oblique 
plane of the inlet of the true jielvis. 
Below it are the bladder, small in- 
testine, part of sigmoid llcxure, 
rectum, and in the female, the 
uterus, vagina, and ovaries. 

The above table of necessity includes organs who<e positions cannot b*i 
present but will be subsoqueutly studied. 

It will be well for the student to notice the tlistinctive appr 
anee.^ of the several parts of the intestinal canid, and pi\rticulaH 
the dillerences between the large and email intestines. The 1 
dition of the intestines varies so much according to the miide \ 
death, that mere size is no criterion, the smull intestinea lieing i 
xioually distended to a much greater size than the large ; but attd 
tion to the following points Y.'il\ -ptevent a\V ■^imIyVaVv.Vij <A cttwT 



THE PEBTTONEUIL 



279 



|.4;ylin<ler of the amall intestine is uuirorm tliroughout, and the 
' I is perfectly smooth, while the large intestine is pouclieil or 
V con.slrict<sd at short iiitennls throughout, excepting the 
. and is marked liy three distinct Wiids of longitudinnl inus- 
;;bres, and small sessile or pediincnlated excrescences of fat 
■ir'.T rpiploicte) vnW be found iittncheil along the line of one of 
In the healthy condition the large intestine is about 
, v '"• "* ^^^ small intestine. 
Tlie Feritoneum (Fig. 133). — The serous membrane lining the 
tlKloBiiiii>-j>el\ic caiity ond covering the viscera is now to lie MtuJied, 
and the student must bear in mind tlint lie has already o])ened the 
earity of the peritoneum, which was pi-eviously a shut sac, and that 
in the normal condition the serous surfaces are everpvhere in con- 
tact, the cavity hence l)eing virtual rather than actual. The best 
way to learn the peritoneum is to trace the reflexions on the longi- 
1 plane of the Ixxly, and afterwards transversely. 
_ .nriing at the umbilicus the inenibninf of tlie greater s&o will 
\k wen to line the posterior surface of the anterior abiloininal wall, and 
llie under surface of the diaphragm ; from tliis it is retlected on to the 
npper surface of tlie liver, forming the up[>er layer of the coronary 
and right and li-ft lateral ligaments, nnd both layers of the falcifonn 
ligBment — fieritoneal folds which fix the organ in iu place. After 
iitreKting this surface, it turns around the Hharji anterior margin of 
the organ, and covers the whole under surface except the Spigelian 
and caaditto lobes. From the transverse tissure it passes down to 
(be stomach, forming the anterior layer of the <jtis!n>-lirfiutic or Uuer 
(muiUuni, covers the anterior surface of the stonisch, and is prolongeil 
downwards in front of the intestines to form the anterior layer of an 
apron-like fold, the great omeiitura or cpiptoUn. Heturning upon itself 
it forms the posterior layer of the great omentum, anri is continued 
upwards until it meets with the tmnsverse colon, the jiosterior surface 
of which it covers. From the colon it is prt^onged to the spine, forming 
the under layer of the IraiuvcTte mt.«>-roli)H. It is now curiied down 
over the mesenteric vessels to the small intestine and back to the 
tpine, forming the two layers of the mrtatlerij \ thenue passing over 
the posterior alxlominal wall into the pelvis, it invests the upper 
jiart of the rectum (nM»o-r«c<um) and in the male passes from that 
tube to the bladder, forming the ndo-retifal pottclt, wliile in the 
female it is lefiected from the rectum on to the upper part of the 
vagina, as the deep recto- vnititial pouch {<■!<! -<li--inic of Ihiirfim), 
then aver the uterus and between the uterus and bladder, forming 
the utero-ctrical poudi. Lastly, it is airried over the bladder to the 
lower part of the anterior aUlominal wall ami so to the umbUioia. 



280 



CAVITY OF THE ABDOMEN. 




It should be noticed that wben tbe peritoneum app 
intestine its twu loniiiite diverge, leaving a triangular interval {p 



Fig. 133. 




section), with it« base at tlie intestinal wall and its apex towwi 
the root of the mesenteric fold. This interval is oixupied by I 



Tig. 133. — Dlagrun of Vfrticnl toctton of the peritoneum (dmim br 
J. T. Gray). 

Tlie continuation of ttii' greater with the lesser bag through the {onuutit 
Winnluw w tiiarkod by iiu aiTow. 

L. LiviT. J. Jpjonura. B. Blmldcr^ 

S. Sloiiiach. P. Puniireo*. V. llrnu. 

C. Colon. 1). Uuodeuum. 'S.. 'Bjs.V 




THE PERITONEUM 




(contlnuoui with ttie subperitoneal tisane), and by the VMSels and 
nervc* vupjilying tlie gut. As a result of this urraii)j;onirnt, nlioiit 
a fourth or a tiflh of the circumference of the intioitinal wall hiM 
nil bcrouii ciiul ; a fact which Uic »ur]'i'Oii mual ix-mvnibur in apply- 
ing ButiiiiM lu rfsvcliun uf thu jtiil, or the " iiitenturotu Irituigle" 
niftv lie invaded by utruvuauU'd fuscal niultor. 

In the female the cavity of the );iiuitcr sue coniniunicatea witli the 
genital panagcs by mitiins of Uie open moutliii uf the two Fallopian 
taboi. 

The grfottr oaf of the ]Mrit^neuni h(W iiow Ir'cu traced, but 

then) 14 nnother i>ouch eddied the leasor aao bvhiuil it, and con- 

tiuaou« with it through u tube nuined the /oritmrn of H'tiulow. 

ThtM forumen will be found by puMing the linger behind tlie 

right frei- border of the ^istr»he]iutic onicniiiin, ininx-iiintcly 

below the lolms CAndntiia of the liver. To exjuwe the cavity of the 

ic^ .1 ioii]i;ilndiiial incision nhotild be airefully nnulo in tha 

line through the two luycrH of the U-mlt oniciituiu, thu 

end of the slumuch, iuid the double lUiterior layer uf the 

.omentum. If the edj;es of this incision be now widely opened 

f of the DOC will l>e viaibli\ It will \m: noticed that it 

lalimm a dc«rp but narrow ]M>uch, cmbnwin^; the lobua Spigelli, 

and expands transvenudy Udow, when- it lie« l)ehind the utoniach nnd 

between the layers of the great ouientuni. Ti-uciiig it in thu lunxi- 

tudiuiJ direction from the tninsverse llasute of the liver, th« uieiu- 

bnute of the leiwer sac will be found to form the jKwterior layer of 

the leaser omentum, imd cover the posterior .lurl'uce of the tttoiiuich ; 

it iit prolon^jod downwanU Ut form the second layer of tho 

ucntuui im far us the lower edge of tlii^ fold, and upward* 

•A^u ii;i the third layer ; after which it covet« the front uf thetmn»> 

TtTw i-nlun an<l fornm the ujUKir layer of the Inmnverne niewi- 

It then iiive>tt» the anterior nurfuce of the ]>nncreua and lit 

d upon the lubuH Spigelii and lubun aiudutui of the liver, tu 

l«auh the traimverse lisi«ure. It will Ih<. noticetl llmt the lobua 

Sptgelii i« the only portion of the liver covered by the jicritoneum 

of the lesser sac, and that the lobus caiidatus coincides in poeition 

the fomnu'n of Wiuslow. 

The Foramen of Winslow (Figx. 134 and 130) ia aimply a 

uf hour-glo^ conatrictiun of thu peritoneum dividing it into 

porta, and i» cauoed by the putwuge of the hepatic artery for- 

ttd ii]>wurd« from the ]>uMlL'rior ub<Iomiiial wall to the 

fi«'-iiiH. When the linger it in the foramen it will feel 

:ii(lnrieA In front, the lesser omentum, contiiining 

.1, jxtrUil vein, hilc duct, and hepatic nerve* myOl 




m. 



■ ^m^.-^d-^.'-i-*-*. 



282 



CAVITY OF THE ABOOMEN. 



Vttl 



lyniphalics ; hthind, the right cms of the tliaphnigm iiud the 5 
Venn cavu ; Mvw, the hepatic artery (aa it pasaea forwartia frtiin tl 
aorta) ; aliovc, the lobiia caudatus of the liver. 

The two sacs of the peritoneum may lie traced together is 
following way. Beginning at the liver, one layer covers the froi 
and the other the back of the under surface of the organ, and ll 
two meet at the tranaverfie fissure to form the leaser omenti 
They then separate to enclose the stomach, tuiiting At its low 
horder to form the anterior double layer of the great omentniD 
reflected upon themselves, they next form the two posterior layi 
which sei>amt« to enclose the transverse colon, and form the tnw 
verse me5o<olon as they are prolonged to the spine. The two la; 
now sepanite. The upper one (lesser sac) is prolonged over 
piuicreas to the under surface of the liver ; the under layer (grealef' 
6j»c) covers the lower part of the duodenum in fwnt ; then fonm 
the mesentery, the recto-vesical pi^uch in the male, and the recto- 
vaginal and \itero-ve,sical pouches in the female, and passes ova 
the ab<lomiual wall to the diaphragm, from which it is teUec 
on to the liver, where the descriiiliou commenced. 

On passing the hand into the lesser sac its cavity ia found to be 
shut off from that of the greater sac on the left side by a doul 
lamina of peritoneum. This se]ital fold is the ijiuint-phrenie 
licno-phrrnk omentum, and will presently be described. 

The peritoneum should now be traced horizontally. Beli 
the level of the trausveree colon the circle will be found to 
excee<lingly simple. Beginning at the me<liau line of the unterii 
abdominal wall, the peritoneum may be followed to the right 
region, where it wUl be found to surround the cavum and to co 
the front of the ascending colon, binding the latter to the po«ten( 
alxlominal wall ; it then forms the nUMiitcrj/ ; and lastly, coveri: 
tlie anterior surface of the descending colon and the sigmi 
flexure (binding the former to the posterior abdominal wall, 
forming for the latter a iufnioid virso-colon), it is brought ro\ 
again to the anterior alxlominal wall. Either the ascending 
the descending colon or both may l)e surrounded by peril 
neum, and lonnected to the posterior alxlominal wall by a 
cuhn ; but in some instances, where a contracted jiortion of 
colon seems to possess a short mesentery, the fold completely 
disapjiears after inflation of the tube, and an uncovered portion •<( 
the wall comes into contact with the parictes. This fact pr. ' 
account* for the discrepancies Iwtween the observations of iliili 
anatomists as to the frequency of an ascending or descending nuto- 
colon. 



THE PERITONEUM. 



S83 



wjfo-fohV fold attache* the s|))i'nic fli-xiin: of the tlt«ic'cnJiin{ 
colon to the nnJer eurfncc of tlif diuphragjii ; it piumc» lirlow tho 
"k-cn Mul Hniit« the lUDVcnientg of tluit orpnn. 
[AlMve the <-olon the nmiiip'iuciit i« eom|ilic«t<?<l by tho rxi«ti>iic« 
' the two 8ac8, the cuutiiiuity of which may here bo ilrinini>.tnitMl 
134). Bvginniiig at the me<liaii line of the ulxluiiiiiiiil waU, 
f>eritoneutu nmy Lie tnicc<l into the rifjht hy^iochotulriiim iilnl 
tr the rij;ht kidney j it Uien jiiwsck into the funimeii of Wiiibiow 

Fig. 134. 




•CTow the l>ody in front <if tlu' {lancreax, iind runs foruiittl to tho 

liac end of the fcluiuach from the diii|)li nielli und kidney, fonnlu^ 

right lAVer of the ijattro-phnnit umtnlum. It then oovers llie 

uterior burfuce of tlic Htomuch otid retuni« tu the fornnien of 

linslow lui tlje |iiwterior layer of the lesser onientiini, Kellected 

tbi« point uixin itself, the iiiembrniie runs to the left us the 

piterior layer of llie leiMter omentum, nud i» continued over the 

of the. Btouioeh ; tlieliee, tonning the uutenor layer of the 

«tc onuiiium, it reuchex the epleeu uiul euelo8eH it, then 

the posterior layer of the goistro-sptenic omentum and 

\it» the bock of the cardiac end of the fitoniuch, from which it 



_ ^. ISi. — TnuMveno HvtJoo of the abdomMi at tha trvrl of tb» foramen ef 
'istlow (dmwii by J. T. tir»y). 

t mnov fwaim frnm llw itreHtvr lm|[ lo tlitt IvMor Im^ of the poritunuum 
I thv iiiremen of Winalow, whicli i« M-eu in tvotion. 

I8. StijiHorli. Sn. Siilrxn. V. Vnttuht*. 

'■p, lluirmit. K. Kiiliiry. A. .Vorlii. 




^ 



passes to tlie diaphragm and left kidney as tLe left layer of tLe 
gastro-phreiiic onieiitiun, and so to the left hyiMX-hondnum tsi 
ro\ind the ahdoiiiinal wall. The continuity of the greater willi 
the lesser bag is thus made evident, and the foramen of Winsluw 
is seen t^ be merely the narrowed tube of communication between 
the two cavities. 

The gastro-phrmie onunlum, passing from the back of the cardiM 



Fig. 135. 




end of the stomach to the diaphragm and kidney, forms the | 
part of the septum between the greater and lesser sacs. It is eon 
necteil nl>ove with the tissiuv fur the ductus venosus on the unile 
surface of the li\er, and with the u-aophagus, and is continuous iti 
front with the left extremity of the lesser omentum. In many sub 
jects the point of reflection of this .septal fold, instead of passing bull 
the stomach, runs from the gastro-splenic omentum, orlrom the spleen^ 



Fig. 135. — Ditgram of the reflection!) of the peritoneum tnced horixontollT I 

the level of the foramen of W iiulow (W.A.) 
1. Point of arrow on IcMcr sac. 



2. Fuli-ifonn ligament. 

3. Ciiriliuc end of otoraoch. 

4. F<?uther of arrow on fireutor sac. 

5. Forumen of Winslow. 

6. Liver. 

7. Gastric Tfl»a hrevia of splenic 
artery in gastro-Kplenic fold. 



8. Lesser omeutuiu. 

9. SplHeu. 
HI. Aorto. 

11. Left kidney. 

12. Vena cava. 

H. Subperitoneal tisiue. 
10. Uight kidney, 




THE PEEITONEUM, 



285 



latter case receiving the nnnie of [ieno-phre}iic omentum. A 

Jl jKirlinn fif the siik-cii wniiM lln>n Ix- co\ crwl l>y the {lerituneuni 

[the leMer nac («» in the miKlel of His ami in Fig. IS.*!). 

Besides the fohL* of periUitu-um wliich liiivo In-en mvinetl in tracing 

iiieuil>ruD«, thvTu an> uthen wiiich fnrni certain liguuients of the 

er and bladder, and of the utenin in tlie female. 

rig. 130. 




PM»lnj» from the umhilicus to the liver i» nccn the obliteruttvl 
■ ■ r round liijnmtixt, an>l nrv)iind it in rellectfil u double 
J . 1 , ■ , im, the Hiupfiuury or /ald/nriii. lii/niiiriit of tlie liver, 

ou^eal ou vni-h side over th>' dinphnujiii and on to the 
of the livei', where it fornix the upper layer of the 
liijammt ; the under layer liein^; formetl partly by the 
: of the peritoneum, and thu triangular surface of the liver 
betWMa the two being attached by brm areolar tisane to the 



Fir. 13*1.- Vm^U p«lrin orKsnt, laen from abore ((Wnn Saragv). 



-trie nrliTriec. 



I lit ui utertu. 



Unr* alUi uiiil ■ortioii of urochut. 

Bbiiarr. 

Soaod ligament of uteru». 



¥. Fimliriatcd extnmitjr of Fallopian 

tube. 

T. FitlliipiiUi tutw. 

O. Ovary. 

B. Itretuin. 

U. L'tiTui.. 

V, Fifth lumbar vertebrt. 




CAVITY Of THE ABDOMEN. 



diaphragm. Thi? tliiplicaturea continuous with the coronAiy 1 
nienl on encti side are called the right unci left lateral lujamenU, 

The faJar lujitmniti of tlic l)la<l(ler, loniieii liy the [leriloueam, (K 
five in number, two {Misterior, two Itttcnil, and one superior. 
The jtostriior faW ligaments are the mai'gins of the recto-viaicj 
pouch, and are formed by the reflection of the membrane or 
the ureters. The Bo-called lateral false ligaments are merely th» 
reflections of the peritoneum from the bladder to the sides of the 
pelvie, and the tuperior is a fold passing over tlie uruchus to lb« 
umbilicus. 

In the female (Fig. 136), the pelvi.s is divide<l tmnsvetsdy 
by folds of p<-rit<ineutn reaching from both sides of the ntems to the 
aides of the pelvic, and called the broach liijnrMr.ts of the utettu; 
they contain the ovaries, the Fallopian lul)es, the round ligament, 
and othei' struclui'es. It is by the open mouth of the Fallopiwi 
tube that the ]>eritoneum has a communication with the mucous 
membrane of the uterus. The uterus and vagina interieae 
between the rectum ami bladder, and the peritoneum is prolonged 
from tlie rectum to the jjosterior wall of the vagina, and then 
over the uterus to the bladiler, forming the reeln-viujinal and 
uttro-vim-<d pouches, and the auterinr and posteriur liijamenti of tbu 
uterus. 

In the child an arrangement may occasionally be found which 
is extremely rare in the adult — the posterior layer of the griat 
omentum ascending directly to the pancreas, and then being again 
reflected to the colon to form its meso-colon. Some indication nf 
this may be seen in the adult in the tmusverfe meso-colon near 
its apleuic extremity. 



Pkmtoskal PoUCHIiS. 

An examination of the interior of the greater sac of the peritoneum I 
shows certain pouclies and fosste, some of which are of surgiealj 
interest The princijial of these are as follows : — 

1. Foam, jihrcnico-lu-putira. — On the under surface of the dia-l 
phragm, beginning at tlie left lobe of the liver and extending to 
the left, ]iarallel to the coronary ligament of the liver. Its diameter 
is from a sixth of an inch to an inch and a half. 

2. FosM (iuoileno-jijiiualu. — Situated at the root of the mesentery, I 
and is exposed by laisitig the great omentum with the colon and 1 
drawing the inteHtines to the right It runs from left to right, and { 
is of variable size, generally large enough to admit a finger. Thei 
eatrsnce is bounded on tlie riv^hl side \^y U\(^ tjermination of th«j 



i>KHITONKAL POUCBSit. 



2M7 



xlcnum, on the loft miIo liy a nomilnnftT hanA of poritojiputn 

containing ilie infcrii^r fiieMi-nt^rio artery bIhivb nnil tlie i-olicn 

istr» lieUiw. ' ■ ■ ti livniiii. 

3. Fiunui inf. ilio iiiJiMlt? of th« root of the 

Old nic-<i>-ciiluii iiu iU It'll tiiL':, iiiiil piuiat'x iijiwiipU ou the innrr 

e of tlie juMMis muvclc. Thin I'loiia ia uccuiiiuually the iKiit uf u 

lia. 

b. f'oMta tulKircaliii, behind anil internal to the ciccnui. 
H, h'oiuui tU<hfnlira. — At thf jiuiRtion of the ileum ami cienum, 
intath a {icritoneal foM (iloo-colic) retWclt'il ovur the nntr-rior 
ileo-colic artery. 

FotM Ueo-cvculit. — Uetwecn tlie lowtr Ixinler of llwj tonni- 
ion of the ilctuu ami the mot of the rurmifonn apjiendix. It i* 
ictitutri double. 

Tbn rjltnuil middlt and intrmal inguinal foum and the neb 
injol jxiiii'h have aln-nily liecn dcn-riVKid. 

The Ki rLWTioNs ok thk pkhitdneim rnoM thk visceuA to 
THr WAI.L or THE AniMjMK.x niiiy bo atudivd on Fij,'. 137. 

T^ie jxwii'rior jicritoneul uttjR'hmenl may Ix-' ilivided into an 
: portion connecled willi thr liver, utoniudi and upleen, ulid u 
' -.- belonpiij; to the liirgo ami «miill intcstiiii!. The uyjfr, 

I comnicncing with thi; relli-ction of the fulrifomi lij^anient upon the 
^^^icpkragni, I'Xtcndx hnckwnnU somewhnt rihliiiuely to join the largo 
^^B«A coniierte«l nitii th<^ jtontcrior Mirfnco of the ri^jht lolw nf tho 
^TiviT and the ri^ht and left laternl li^'aiuent«. From thu lower 
I border of the hepatic area riiUB the ]x>Mterior allachnienl of tiiat 
' .liiiit.le layer of peritoneum (gnBlro-phrenic or lieno-phri'nu' fohl) 
>»lii. h funua the trptum between the greater ami leiwer »aci> of peri- 
ineum on the left side (Fipn. 134, 135), and encloses the ttso- 
oguK, the toil of ihi- jianrivns, and the epionic vcmcU ; thi!> ]>a.<>.'«e» 
tlie jHiint nt which the vena cavn rcceiveM tbo obliterateil ductun 
lOBOs, obliijnely to tbe h-ft AcrofM the diaphnigiu to the front of 
kidney, wher« it Joina the attachiueut of the splenic ttexura 
«olon. 

hnm line of attachment conrniences with the root of the nieaeii- 

jm iLe left tide of the 2nd luuiWr vertebm at the termination of 

(tage of the durxieniun. From this point it runs oblicjuely 

! •-- the i*[iine into the right iliac foes»\ where it meets the 

lowe-i .'it of the ii8cending colon and of the littli- ii]>[iendi- 

caljir tulU. rhe ascending colic area mnn upwardu over the iliac 

cnMt, tiif anti-rior lamella of the tniiuverHilig tendon and the front of 

the n.' : it is succeeded by the attachment of the lraniiver?e 

<ii exU-aJg tmnnvvnyely oci-oM the itiual vc»ftc\« atii 




288 



CAVITY OF THE ABDOMEN. 




Fig. 137.— Diagram of the porietnl attncbment of the peritoDoom (M 

Delcpine) . 

1. Upper ond of acptal fold between U. PortuI vein below fanuea | 

greater nnd leoer eaca. Wiiulow. 

2. Qv8i>j)biigni.<i. 12. Tail of pancreoa in gostro-ph 

3. Fnlnforui li(r:imcnt. omentum. 

4. 1.1-ft lutoral li):im]rat. 13. Bile duct. 

6. Veua cava inferior. H. Costo-iulic fold. 
G. Iliaphragm. 16. Hepatic artery. 

7. Phrenic artery. 16. Tninsveree nieaoeolon. 

8. Cut edge of peritoneum. 17. Bight bitenil ligament. 

9. llepaliij area. 18. Aorta. 
10. Splenic artery behind le«eer eac. \9. V-jYotm*. 





MiilSENTElUC VESSKLS. 289 

the pancrean, tnuisuittin); between its kyen the terniinaiion of the 
fint 8tat^ of the duodenum above and im the right side, and the 
end of the third stage at tlie middle line ur a little to the left ; and 
leceiving at its left extremity the luwcr end of the Ki-|ital fold 1>vfor« 
referred to. At this point it becomes continnous with the deitcend- 
ing colic area, which runs downwards over the kidnvy und tnuisvvr- 
sttlis tendon into the left iliac fi)ssa. The desceiidiiiK culie urea is 
succeeded by the attachment of the sigmoid iiieso-culou and meso- 
rectum, which crosses obliiiuely over the Micru-iliac joint to the front 
of the sacrum. 

MK8ENTERIC VEHHEUi. 

[In onler to dissect the mexenteric arteriex, tli» greut omentum and 
traniiverse colon must lie tunie<l up over tlie (^uriilagi's uf the ril)s, and 
the MUiall intestines be drawn down. Beginning ut the up]>er end of 
the jejunum (t.«., at the ]Hmit where the xmali iiiteMine eun tirwt be 
distinctly wen, usually on the left Hide of the IkhIv uf the thii-d 
luml>ar vertebra), the dir<8ectur should remove the whole uf the 
anterior layer of the inexeiitery from it« riMit down to the i-d^e of th'j 
Ijowel, where it in to lie cut o'tf. Thin must be continued aloii^ the 
whole length of the Hniull inteHtine, and the iiieiientcry will lie found 
to pasw <il>li(iuely downwards from left to right. AlU-r the veswels 
contained in the mesentery are cleaned, the iin<ler layer of the atcend- 
ing and ti-ansvene meso-cohm mibtt lie i-eiuoved in the Kinie way to 
ex{>ow: the vessels going to tlie lai);e intestine.] 

The Superior MoMnterio Artery (Fig. I3H, lo) is the vessel 
which tupplies the small and half the lai-gu intestines. A branch 
of the aljdominal aorta, it conies off opposite the. first luml>ar vertebra 
immediately behind the neck of the puneifas, and is embraced by an 
inferior extension of the head of the organ, wliieh passes liehind both 
the artery and vein. It runs forward Inftweeii the jianereas and tlie 
transvei'se duo<lenum, giving off the inferior iHiiirrratint-damlenal 
branch (13), which takes a curved course to the right U^tween the 
head of the x>ancreai<i and the duo<lenum, to anastomose with the 



jtO. DetecndinK colon. 32. Common iliiir itrtvry. 

31. Superior mcwuteric srterj'. 33. Viisii intotini tcnuia. 

{22. Left kidney. ' :i4. Iliac fcisNi. 

23. Termination of duodenum. 'Hi. Left rnniiuuii iliin' iirtery. 

94. Metentciy. 3(j. Iiitvrnul iliav iirtery. 

35. Descendini; duodenum. 37. IVlvix. 

96. Coliea iini>tra. 3tt. Ii.\temiil iliac artery. 

S7. Kight kidney. 39. Kxteniul iliiic iiilery. 

■Si8. Sipnoidea. 40. Deep I'liipuitric urti'ry. 

29. CoUcadcxtn. 41. Mew-n'<'tuni. 

30. Superior hannonfaiddal arteij. 43. Kei'tal areu. 

31. BifhtMlie an>. 4a. lilsddcr. 

H. 11 




M£SKMT£B1C VESSELS. 



miprrwr pancreaiicKhduodmal artery. The trunk of the Buperioi 
mesenteric artery will tben be seen to Uike a slightly curved directiot 
from left to right, and from its convexity or left side are ^ven the 

Fig. 138. 



i 




branches to the small intestine (l6) {vasa inlegtini toiui*), whil| 
from its concave right side arise three liranches to the la 



Fig. 138. — Courae and dittributinn of the superior meienterin artery 
(from Wilaon). 

9. Deacfiuling colon. 



1. DeKending portion of the duo- 

denum. 

2. Transverw portion. 

3. I'ttncrea*. 

4. Jejunum. 
6. Ileum. 

6. Cn'cum nnd appendix Temiiformi*. 

7. Ascending colon. 
b. TruurenM colon. 



10. Superior mesonterid artery. 

1 1 . Colic'41 media. 

12. lu aniutomotus with tb« coli 

^iTiistni. 

13. Pnntrfatifo-duodenalui inferidr.^ 

14. C'olini de.xlm. 
Id. Uen-iolicii, 
VC, IQ. Viua intMtiui tnkuia. 




MESENTKTIIC VESSELS. 



291 



f, 'Ito-eolic (15), riiilit culur ( 1 4 ), and midilU rolie ( j 1 | nrtcrii^ 

in their onler frniii Ix-luw hjinvudIs). Tlin lirunchei to tlin 

Itexline form u stiie" of I'riiimrv, nerimilury, ami »<)iiittiiiie« 

' loup»i which iuo»cul«te fn-tly willi mif unotluT, und j-ivi' off 

Fix. Ian. 




tig, 13S.— Bnmchn oltite inferior maMnteric sriiirj' (from WiUen). 



|1- Ti. 



f mtuentrrir antl 
t« tumrd over to 

adix DiKi. 

culuti tuni«d upwiinla. 
( eolon. 

MMI*. 



8. Ah.1-.., 1 .. 

9 Iiifc I If nrtnrjr. 

lU. Coll. J luiculntlnK with — 

U. Coliru nii'<liu. 

12, 12. Siifiiini'l hninplir'. 

13. Sufxruii' tu'iuorrhuiilal itrteri . 
II. I>.ini-n<iu. 

la. Dotcending portion o( ibe liun- 
denuni. 

V i 



292 



MESENTEUIC VhSSEf-S. 



straiglit bninclie* (longer in llie upper than in the lower part if tb 
mestntery ) to thu inUaline, each of which breaks up into 
twigR, one for each }iiilf of the segment of gut supplied, 
branches to the large int«stino take the course indicated l>y tbti 
names ; thuH the ileo-colic goes to the end of the ileum and i 
niencenient of the colon (aocum), the ri>;ht colic to the ascend 
and tlie midille colic to the transverse colon. Each of these aiterj 
divides into two Ijranches, which spread out one on each *ide to ina 
lute with the adjacent liranches of the neighlx)urinfj; vessels, for 
tile primarj'kKipg; the ileo-colic also anaKtnniose with the vasa in 
tenuis, and the middle colic with the inferior megenleric ar 
thus a free anastomosis is established from one part to another of t 
intestinnl canal. The colica dextra and the upper branch "( tli 
colica sinibtnt pass beneath the peritoneum in front of the riglit am 
left kiilneys reeix-ctively, and hence the peritoneal incision for in 
peritoneal nephrectomy should be made on the outer side of 
colon, unless there is any sjiecial reason to the contrary. 

Convspiinding branches of veins will be found miming willi i 
arteries, and ojieiiiiig into the Superior Mesenteric Va 
(Fig. 147, 5), which unites witli tlic ^]>l^•Ilic■ to form the vi'UA 
]iortiE. In addition, there may be found ramifying upon til 
arleriwi tlie branches of the suiierior mesenteric plexus of ne 
derived from the solar ]ili\us of the sympathetic ; and intersj-rr 
are the lymphatic glands which receive the lacteals from 
intestines. 

S'he whole of the small intestines are to be turneil over to tk 
t side, anil the remainder of the meso-culon, as well as tbt 
peritoneum intervening between the ilescending colon and the 
■pine, is to be removed to exjiose the inferior mesenteric vessel*.] 

The Inferior Mesenteric Artery (Fig. 139, 9) will be *e« 
to arise from the alxlmiiinal aorta about an inch and a half above 
the bifurcation, and to Uike a course downwards and slightly to the 
left. It gives off the left colic (10) to the descending colon ; tie 
ligmoid (12) (three or four) to the sigmoid flexure; and lastly, 
the tuperior hainorrhoulal nrtery (13), which descends into the 
pelvis to supply the rectum. The.se arteries anastomose freely 
with one another, forming loops, and moreover, the left colic 
inosculates with the miildle colic of the sin)erior mesenteric, and 
the superior lucmorrhoiihd with the middle ha^morrhoidal of the 
internal iliac artery. The t.uperior hosmorrhoidal artery, at toA 
single, bifurcates on reaching the rectum, and its branches run one 
on each side of the gut. 






THE CCELIAC AXI8. 

The Inferior Meaentario Vein (Fig. 147, 4) will lie s«en to 
have tributaries conespouding to ihi: bniuclit's of the artery. The 
lowest of these in the «up«-iiiir hx-iiiiirrhoi<hil, wliich nnntitoinosivs 
with the middle hteiiiorrhoiitiil (6), a triliutary of tin- inti*nm) iliac 
vein, thus forming a comiiiuniuatiini IietwetMi tliu two gr>-at veiiouM 
systemg. The inferior nuiscnteric vein iiaMcx iipwanU Ix-iit'ath tho 
pancreas to join the splenic or superior inesi-nttiric vein, and xn into 
the vena portcc. Branches of the inferior ni&'<*'nt(>riK ]>lc.xu!i of the 
sympathetic may be traced upon the vessids from the aortic plexus. 

It may be noticed tli.it thii ineseutvric vein.4 have no valve.>i and 
consequently never present dilatations. 

ThR CtKMAC Asi8. 

[The intestines are now to be rc)>lacc<l, and the liver foMtcniMl up 
tu the ribs, eithiT with hook.i or, bettor, by a few Mtitchex ; the 
stomach being then drown down, tht> Icxser omentum ix to be 
cAiefuIly removed.] 

Between the layers of the lesser omentum near its free Iwnler 
will be found three important structures, in the following n:lation 
to one another (Fig. 143). To the right and most in front is the 
bile-<luct (7), to the left is the bp]>atic artery (5^, and 1>eliind and 
between the two the laiyt; vena portiu (i)). 

Behind the lesser omentum in the middle line will be found the 
abort trunk of the Coaliao Axis, which springs from the front of 
the aorta opposite the disc between the last doi-sal and first Iwubur 
vertebrse, and runs al)ove the neck of the i)anrrvas to break up into 
its thieu branches, viz., the gaoti-ic (eomnaria ventrii-uli), the hepatic, 
and the splenic arteries. The braiirhes iire to be cleaned as far 
as exposed, but the cculiiicaxix itself shoidd be b-ft for the present, for 
fear of injuring the syinjMithetic plexuses surrounding it. 

The Oaatrio or Coronary Artery (Fig. 1 40, 1 2), the smallest 
of the three bronches, runs at (irst u])wan.ls ami to the left in a 
daplicature of peritoneum, called the left ]i!tiicreatioo-ga.'>tric fold; it 
then passes along the lesser curvature, of the stomach from left to 
right between the layers of the leaser omentum, giviiig branches to 
both surfaces of that organ and to the ie.sophagus. It ana.stomoses 
at the pylorus with the pyloric branch of the hepatic artery, and 
by means of its first or a>so]>hageal bmncli, with the (esophageal 
branches of the thoracic aorta. ISranches of the sympathetic 
(gastric plexus) may be traced upon it. lU accompanyiu); m'a 
opens into the reaa portto. 



THE CtELlAC AXIS. 

TLe opportunity may be taken to notice the distribiilion 
]>neumogastric nen'e to the sionmcb. The left pnirtiru 

Fig. 140. 






THE OA8TRO- DUODENA I. AHTKUV. 



fpvM nuiDvroiu bniticlien tu the front of the Dtutuncli. ami the vi^hl 
Ui ihv buck uf the vinus, iuiJ ihrei- cuii b« ){uiivritll,v aeeii thruiig)i 
the pcritoiityil conl without furtluT (iifMt-ction. 

The Hepatic Artery i. Fig, 14u, t) cun'fi upwurdR und to the 
right siiU, forming the infiTi«<r nnd nntiTior hmimlaries of the 
fonaiirii of Wiiislow, anil ernln liy dividing into thn right and left 
hrpiUic liranrhf*, which enter tlic traiisvcrxc fiamirt- of the liver. The 
artery p^-en oil llr»t the vylont branch (3,1, which lias been «eon to 
annstoiuosi: at Uic up[>er bonier of the pyloric end of tlit> Htomach 
with llie gastric, and secondly u trunk which ininie<liutely di««pf>e»nt 
iMrhind the first portion of the duoileniim and in culled the i/tulru- 
rniil (ij). Kriiiu the ri^ht hepiitic lirunih u given ulf the nmaller 
(7) Brterj', whith i* distribut*-*! to tlic )jall-bludder l)y two 
Bche*, one jiuMiiiig U-tweeu it and the liver and th« other alonK 

miriuce. 
The Splenic Artery (Fig. HO, 20) ciin be neeii only in 
taking a tortuous cuur«e behind tlie Htomach and along tlic 
ui>pcr borilcr of the panctvo* to the xjilecn. 

[To continue tlic diwiection it will be nece!«««ry to remove the 
intestinev which have lieen rtHniined, by putting a couple of 
■ n the upper piirt of tiie Jejutiuni, and ul»o njwn the 
f the rectum, and dividing thi' intestine lietween the 
ftt eftcli iMiiiit. IJy cutting the sujierior niewnteric 
null intestine will be at once wt free, but the large 
■M.i-l be curcfuUy removed by dividing the nieno-colon 
{4^MkJ* Uie intestine througlioul, and liully \>y cutting the inferior 
-aaCMateric artery. The gastiv-duixJt^nal and gplenic arterie* and 
their brauchet are then to be cleaneil.] 

rir Oaatro-duodenal Artery (Kig. 140, 13) can be traced 
by turning up the vtoiuuch. After poiuing behind the hr«t 
p«rti<.in of the diii>lenuni, it divide* into the right giiiitro-epiploio 
and the »ujicrior j^>ancrealic<Mluodenal arteries. 

The OaMro-qiiyloica dexiru (23) runs from right to left along the 
great curvature of the ktoiiutch lietween the folds of the great 
omentum, i!Upplying bnincheii to Imth surfaces of the Btomach and 
til tlie omentum ; it oiuutomoseit with the gastro-epiploiua liniittra 
of the Hplenic arttry. 

The t'nvfrratico-iiuwirnalu nipfrUrr (17) will be found l)etweeii 

the cluiMlimum and the head of the pancreas, xurrounding the latter, 

'.; both ; it «na»t<imose? with a Kniall bmnch from the 

111 of tlie sujierior metienteric artery called the pancre- 

0tf. 'i< I'li/rrior (Fig. 138, ij), and given branches to Itoth 

Mbiii i; / illiojetiiutl. 






296 



THK OlELIAC AXIS. 



The Splenic Artery (Fig. 140, 20) can now be nevn in 
whole of its i-oiu-se In llie spleen, nnJ breaking up into four or 64 
terminal brancht"s, which enter the hihini on the concave unrfacel 
that orgnn. It runs behind the posterior hiyer of the lenstT xm i 
peritoneum, acroRs tlie left kiilney and ftl)ovt' the pancreas, aiul 1 
ttpproucliing the spleen it enters the lieno-phrenic omentum will 
but above, the tail of the pancrea". As it pa«so:< along the upp 
border of the pancreas it gives off small bmnchi's to it {pnnrrialu 
pan'ir), and a larger om- (pim-wiriVu ii)iiii)iii) wliioli riiiin along 
whole length of the gland from left to right, with the lUlct. It 1 
gives branches (viua hrrvin) (14) to the gn-at end of the xloina 
jmd one of larger size {yoMro-epiploicu iinulTn) (18), which ru 
along tlie great curvature, between the layers of the greater onieutu 
III nnastomoKe with the giistro-eiiiploicadextra of the hepatic, suppi 
ing branches to both surfacca of the stomach arnl to the oin»nlia 
Upon the liepntiu and splenic arteries are corresponding jdexa 
of the fynipathetic. 

The Splenic Vein (Fig. 147, 2) is placed below its artery, and 
lies behind llie upper bonier of the ])ancreas. It receives tributarit-« 
cori"e«ponding to the branches of the artery, and usually al^i> tbr 
inferior mesenteric vein, hut the latter may enter the snpt-rior 
mesenteric "cin. It is joined by the superior meseuterii' veii^ 
behind the upper border of the head of the poncreaif, the two fon 
ing the vena j>ort{c. 

[Tlie pancreas and dnodentim should now lio thoroughly defin 
antl the liile dnct and the pancreatic duet traceil to their enlnuw* 
int.) the intestine. If desired, the stomach may lie removed If 
tying and cutting it near the pylorus, and at the (esophagus.] 

Tlie Stomach is a somewhat pear-shaped viscns, with the gr 
extremity upwaiTls and on the left, the smaller end at a lower Icvrl 
and on the right side of the median line. It receives at its larger 
or cardiac end the terminatioti of the tvsophagus, and ends at its 
smaller or pyloric extremity, in the duodenum. The expansion seen 
on the left side of the (esophageal ojiening is odlcl the '/rrti/ ciil lU 
tac, anil a small fusiform dilatation near the jiylorua is calleil the 
niilruiii jnjluri. It is cnveied l.iy the peritoneum of the givater aac 
in front, and by that of the lesser sac behind ; and these layers 
unite above and Ijelow at two lines, the Ifun and grfntrr citr 
niiniing between the u'sophageal and pyloric extremities, 
lesser eiin'e gives attachment to the lesser omentum, and is 
contact with on anastomotic loop between the coronary and pylo 
lb ; the greater cur\'e is conuecleiV \v\v\v V\\fe ^'ivvct - 






THE STOMACH. 



21)7 



below and with the gaatro-Mplenic nmentum on the left, and ia 
timTerwd by the right and left Kastni-vpiiiloic vchrvIh ((|. v.). The 
■tomaeh in the dead subject, unlera much distendt-d, is tlatten<>d 
from before backwards, and presents two surfocvM and two )M>rden< ; 
bat dnring life it is probable thut tlie or^nn i» iwuidly cylindricnl 
in section, and that the inferior borilcr or pt-atiT oiir\>tiiTe iii 
tuned forward towards the alKloniinal wall. At tiie antrum pylori 



i - 




the stomach turns somewhat baokwiinls to Tvuvh tin- noirk of the 
gall bladder. 

Bdatim*. — The anttrior Burfucc, lM-loii(;iiig t« the ;,'r<'iit«r hoc of 
peritoneum, looks forwanls and ii])wardf<, and is ojipoKi-tl to (1) the 
left lobe and part of the lobui* qnndrntiis of tlii.- liver, {'2) thu 
diaphragm, and (3) the onterior aponi-iirosi.<< of tlic triuisvcrsalis 
mnsele. The poilerior surfacf, lH>loii<;iii<{ to tlic letter luu-, i^ 
related to (1) the Apleen, (2) the ]>iiii(-rcii.v, ^3) tlit> left kidney 
and supra-renal capsule, (4) the thiixl .stage of tlic <hiiKli-inini nvnr 
its termination, (5) the splenic and left ifiml vc-s.'<cl:<, (0) tlie 
commencement of the alxlominal aortn, (7) thu xolar plexus and 



Fig. 141. — Oiagrem of the aiitorior rclatinnx of the stonmvh ( W. .\.). 

1. Outline of right eostsl border. 4. Cohm. 

2. Outline of Im costal bordrr. 6. Gull kliiddrr. 

8. SMmdJ^uaeat 7. I'oaition of riRht M'ntUun&T Vvivr. 




298 



THE STOMACH. 



semilunar ganglia, and (8) the cniru of the dLa[>hr«pm. Bdau il 
is usually iji close rclatiun lo the transverse coU'n. but oceaiioniDj 
tlie oilou appejirs to earn,- u|> the great omeutuiu and put in 
Trout tjf the stoiuacb. i.Sec- ]ilates iu Rudinger <U)d Symington.) 

i'ig 1*2. 




The spleen lies to the left of the gKkt cnl de cue as well ■» 
LichiiuL 

The eardiae orijict lies alioat an inch to the left of the middle line 
on a level M'itk the tenth duisal vertebra, and behind the junction 
of the seventh cu»tal cartilage with the steraum in front. Tlw 
Jffmis orifia is usually found behind tlte quadnte lobe of the lircf, 
oa a level with the first lumbar vertebra and about two inebe* 
tu the right uf the median line ; but it eiteii* more to ih* 
right vhcoi much distended, and is retracted tovarda the left ■)«■ 
easplj. 

The BibaU iBtaatina extends from the pjrloras U> the jmetioB 



Fit. 1«S.— Da^raa tt the 
ftaai tke frvrt. tke 



nlMkaaaf tM 



CK^y. 




THE DVODKStTC. 



299 



emewm and oilim. It is on umucculatcd tube, avenKin;; 

28 fo«t in U'D^'tli, with a riuip- t)f vahnliuii from ft lfl'6 

,31 '10 (Twv*:^), »iid ciiiiiinixlii-!! in the wiJth of it* caliUre 

the lhickne<» of il» wttlU fniui it* cnmniencfim'nl tii it* t«r- 

Mion. It is siiMividbd into thn-e ]»ortion», the dutidt-iiuiu, the 

]nm, and the ileum. 

The Duodenum 'Fig. 143, 1 1) i« from eight to ten inches long 
elve fiuger-V)i-eadth»', and mtikea a jieculiar )>»nd upon it»clf 
it [>«i«es beneath the sujH'rior niMcntcric vessel", iin<l joins 
juutim. It lie« in tlie cpigantric and the umbilical regions. 
lie Jirti or turrniting poiiiim, al>uut an inch in length, runs IxvcV- 
and to the riglit in contact with the lobus q\iailratiu and the 
at part of the right lobe jirojKT of the liver, thete lying in 
prrixintity to the neck of the gall-bladder, and renting against 
I ^wcial tmprNwion in fn>nt of tlie lubus ciuidatu«, iutenial l<> and 
reen the rtsnal and colic iiiipri-siiion« (Fig. 157). It is covered 
in front and behind bv u proIoiiKation from the lessor oraen- 
aml is therefore movable with ihe dtoninch. Behind it are 
vena ]iortu!, the couinioti bile duct, the giuitrx>duodenal artery, 
1 a jtorlion of the head of the jMincreus. 
lie »riv/ii<y (tTilrtffuding /(orfi'mi, three or four inches long,)s partially 
til in front by tlio gn^ater sac of the peritoneum and crossed 
' the right extremity of the root of the tranavertc nieso-colon. 
bound down to the surface of the right kidney and supm-rrnal 
f, overlapping also tlie renal venseln, and descends for alKiut three 
our inches beJiind the transverxe colon, caching nearly as far as 
iljuc crest and to a level with the lower part of the botly of the 
lumlxtr vertebra. It lies in contact with the outer side of the 
of the pnncreiis, the jtancreatico-duodenal vea.wls intervening, 
the bilJAry and ]>ancreatic ducts pierce it near the miildle of its 
surface. 

third or tramnrtr portion, four or five inchea in length, is 
fixed to tlie abdominal wull Iwlow the line of attachment of the 
^MK>-colon, and is covernl in front by the ]>eritoneum of the greater 
^■i except where it is cmswd anteriorly by the »u])erior mesenteric 
^Bels. It ruus oblifjiiely upwards and to the right across the 
^Bt of the aortA, vena cava, and thoracic duct, from the level of 
^Btbird to that of the second lumbar vertebra, at the left side of 
^Beh ihe gut receives a complete covering of peritoneum and 
^HBtuei tlie jejununu Immediately above it are Ihe head and the 
^^nr of the pancreas, with the. inferior pancreatico-iluo<lenal and 
^H^ixr ine$enl<-ric vcASels, the latter ufterwardi becoming anterior 
^B. Jt is tunviiitded by nu biieritoueal tissue, and siwjwndfciV Vy 



300 



THE DUODENUM. 



n bund of inToluntary numcuUr flbrt- (tibn>-iuusculiir banl of 
Treiti) to the left cms of the diaphnigni. The entrance of thf 
peritoneal /ojum duodtno-jtjunaiiA (p. 285) lies npixisite tht; juncliun 
of the Juijdenum and jejimunL This i» the nn>st rtved portion i.f thif 

Fif. U3 




<iiuu11 intestine ; and, owinj,' to thu weight of the reuiuinder of the 
bowel, it i« at the junction of the diioilenuni with the jejunum thui 
laceration incjst conuuonly occurs in cases of iiMominiil injury. 

The Jejunum and Qeum arv completely covernl with penlo- 
neuni, except at the interval between the two laiuinoi of the 8cp>ii> 
membrane (see p. SRO and Fig. 1 1-1), and are fixed to the spine 1>; 



Fif . 143.— The duodeniini and 

1. Bound lipiment of licrr. 

2. Ureal t'liii of •tonini-^h (<'Ul). 

3. fiHll-l.ladder. 

4. Spletn. 

6. Hepatic art*ry. 

6. Coronarj- arlcr^-. 

7. Common hiU- duct. 

8 Sjdeuir artery and vein, 

y. Venn porta'. 

10. Tail of panrrena. 

11. Duodenum, 
c axis. On each aide of 



it* relntiona (altered from niranhfeU and 
Leveille] . 

aorta at thii poinl ara that 

lunar ^n^lia. 

13. He»id of (Minrreiia. 

14. Left renal veaat'U. 
Id. Superiur meaenlerix artery . 
10. Left ureter. 

17. Ri^hl kidney. 

18. Left (tpermatic veas^la. 
1ft. Hijfht ureter. 

20. Inferior miseuteric artery, 

21. Kij(ht iiiennatic vea»U. 
the 'il. KoTXo.. -13,. Vaua.ca.vx. 




TUK TANirKKAS. 



301 



the mewntery, wbich extendii from the left Nde of the M'cond lumlMir 
VMtebn obliquely acToiw the itpinv into the ri^ht iliac fo»M when: the 
ileum join* the cawuni. The coiuiuenci'iiit'iit of the ilvniii i» arbitrarily 
fixed at the junction of the seconil with the 
third fifth of the length of the conjoint tuW. >'>«:- 1^*- 

A foetal relic, reprcK-ntin^ the omjihalo- 
mesenteriu duct, and known as MrckeVt lUrrrti- \ . 
euluiu, is occasionally found us a narntw tube, 
from holf-an-inch to five or six inches in length, 
opening into the ileum at a distance of eighteen 
iucheit to three feet from the ileo-ca>cal valve. If 
long it may ran upwards to the umbilicus. 

The Fanoraaa (Fig. 146) lies transversely in 
the abdomen, occupying the eitigastriu and left 
hypochondriac regions, and is sulKlividitl into a 
head, body and tail. The hrad is embraceil by 
the duodenum, and sends a pn>cessduwn wiinls aud 
inwanls behind the superior mesenteric vessels ; 
the body, which is concave jMisteriorly, crosses 
the aorta and left kidney opposite die Iki luiiiluir 
vertebra ; and the tail runs in the gustro-sjilenic 
ur lieno-splenic omentum, to come in contact 
with the lower and back jMirt of the viscciul 
surface of the spleen. The median Hu;;ittul ]>luiie cuts thmugli the 
neck and the lower ]irocess uf the hett<l. It is related in front with 
the {losterior layer iii the lesser sue uf ]ieritoncuni, und neurits lower 
Iwider with the attnclinicnt of the tmii!<vci-se mcso-colon ; und more 
anteriorly is coveted by the stomach excc]>t over u sniull ])i'ojectiuu 
from its U]iper border, the tulMT ommUilr, that rises iiliove the lesser 
curve of the oigan to reach the lesser omentum. I'wifriorly ure the 
crura of the diajjliragm ; the vena cava ; the cummenccmeut of the 
portal vein and its formative tributaries, the sujivriur mesenteric and 
splenic veins, with the inferior mesenteric usually joining the latter ; 
the aorta and the origin of its sujierior incsi'Uteiic branch ; the 
thoracic duct ; tiie axygos veins ; and the lert kidney and renal 
veaaela. The upper horder is in contact with the cccliuc axis and 
splenic artery, Uie foirer honlrr is in close relation with the trans- 




Fig. 144.— The relation of the peritnncum to the wall of the tmsU intestine 

(W.A.). ' 

1. McKDiny. ppritoneum. 4 . . ■ 

2. Fat on iatenaroiu triangle. &. 8<>ri>sa. . . ^ , . - 

3. Artery. 6. Muwulari<' 

4. Vai^tmatmaaadaiiMuaecireTedhy 7. Murosa. 



302 



THE PANCKEAS. 



verse (hiodenum, except where it is separated from it by 
superior meseuteric vessels. 

The duct (cuiial of Wirsung) begins usually >iy two bratichia 
the tail and runs from left to right, gathering xniall tributuriei fn 

Fig. US. 




the body, und receives two larger braucbeii, one from the I.iwd 
extension of the head, the other from a portion of the ui)]»er port i 
the head, which may be more or less completely separated from tfa 
rest by dissection, und is sometimes called the tfs'rr ^Kiiu-rfat. 
main duct then piei-ces the middle of the second stage of the du<Mli<iiug 
and opens intu the gut by an aperture common to it and tlie ducig 
communis choledochus upon the summit of a small ]>a]iilla. 
duct of the k'Hser pancreas occasionally opens separateljr into 
duodeniuii. 

The liarge Intestine is a wide sacculated tube adapted for I 
retention and final digestion of ficcnl matter, and averages about i 

Fig. 145. — The pimcreu expoH'd after removal of the ttonuoh and tnuunrmt 

colon. (From the model of His.) 

Over the dividt>d vipper end of tlie duodenum arc seen the portal rv'm. hc}« 
arU'ry und bile duit. Tlie rout of the tmniverse meso-oolou rxCondi aii 
pancreas between the cut extremities of the colon. 

tr. Riebt aupm-renal capaule. pt. Colica dextra. 

tif'. Left oupra-rennJ capsule. p, Pnnrreaa. 

rk. KicUt kiduey. «i. Mesentery (cut). 

«/(/. Spleeit. (//. Termination of duodenum 

ufc. tvL Ascending colon. 4. Duodenum. 

/it: Lett kixlney. drict. cot. Unccaduii <wW. 




THE LARGE INTESTINE. 



303 



in length. It commenceii in tLe right iliac foseii niiJ ttrminatea 
at the anu8, and is fulx]i\'i(ied into three segments : — The Cu-'cuin 
ur Caput csKum coli, the Colon, and the Rectum. 

The Citcum is a short hut ca])nciuu8 cul de sac, averaging ahout 
S^ inches in length, and lying below the point iit which the ileum 
opens into the large intestine. It has a cuniplete peritoneal cover- 
ing, and presents at it« lower and back ]>:irt u little ajipeiulage, the 
appmdix rrrmiformu. It usually lies in the right ilinc fossn in 
coBtact Mind with the psoas and ilincus and iliac fiistia, the 
external cutaneous nerve, ami the veniiiform np]K'ndage ; antm'orhj 
it reaches the aMominal wall, and might he exposed b)' an incision 
on a lerel with the anterior siijierior iliac spine, but it varies 
greatly in pobition in different subjects and under dilferent con- 
ditions, sometimes extending downwanls and invvaritH along 
Ponpart's ligament, towards or even Ijeyoiul the median line, 
^^Othen terminating two or three inches below the iliac crest. It 
^■y be overlapped partially or completely by coils of ileum if 
Bsdistended. On its inner side arc the .^mall intestines and t)ie 
jtmciion with the ileum. 

The Appcndij' J'trmifomiu is a blind liibulnr prolongation of the 
diameter of a goose-tjuill, averagiii;; about four indiea in length, 
but ranging from one to six inchrsi ; and most commonly runs 
>1» and inwards, but may a.«surne any direction. It is sur- 
ndcd by peritoneum and provide<l with a sninll mesentery. It 
not infrequently the seat of ulceration owing to the im[inction of 
intestinal concretions or other foreign bodies. 

rbc Colon is subdivided inlo four jiarts, ascending, transverse, 
ending, and sigmoid Uexure. Its entire length ranges from 3^ 
Bt, and averages about 4^ feet (Treves). 
cum and colon are distinguished from the rest of the intes- 
tinn by the 5)eculiar sacculation caused by the shortness of the 
loDgitudinAl fibres of the muscular coat and tlieir arrangement in 
"^ ~ ~ f'Or Itenitg, and the colon present.-* in addition little fatty 
I called appendieet epiploint, attjiclied opjMisite one of the 
UHiias. 

The atemdiiig colon is usually covered with peritoneum only in 
front and at the sides. It begins in the right iliac fos.<ia above the 
level of the anterior 8Ui»erior iliac spine, and runs upwards, cnwsing 
llie iliac crest a little to the inner side of its mid point, to reach the 
internal lamella of the posterior tendon of the tninsversalia (over 
the ijuadratus lumborum). Continuing its course, it passes in front 
of the right kidney external to the second part of the duodenum, 
t«ache* tlie inner surface of the right lobe of the liver, foruiin^llw 
*ie JUxure, and is aucceeded by the transverse colon. 







304 



THE LAHOE INTESTINE. 



Tlie trantverte colon is invested by p>eritoneuia deriveil frui 
Kocs, anil runs in a curved diiviition inwunls, forwards, and sligli 
dowuwaids to the anterior ulHloniiiial wall (but is seiiarate<l from 
by the anterior double layer of the great omentuui) oppcisitc 
unibiJicUN, thence outwai'd*, backwai'd* luul upwaitU to the Ic 
end of the sjileen, where it benilsi to form the ejilentK- flacMft. 

The dttcniiHwi colon bej^ins below the splenic flexure, and like 
ascending cidon is usually bound down to the posterior nbdonii 
wall without the intervention of a mesentery ; it possei downw 
over the front of the left kidney, the transversali;^ tendon, and tl 
crest of the ilium, about an inch to the inner side of its mid {Mii: 
til enter the iliac fossa. The ffut then developea a mesentery »i 
becomes known us the sigmoid flexure. 

The tlgiiuiiil flexure resembles the rest of the colon in its jjent 
characters, but is invested by peritoneum along its whole Icnj'tl 
and is fixed to the al)dominal wall by a nieso-colon. It tir^t rui 
downwards and forwanls, vejiching the anterior abdominal widl 
the inner side of the anterior superior spine of the ilium (where it 
may be exjiosed in inguinal colotiiuiy) thence posses backwards inli 
the true pelvis, turning ujion it«elf in oji S-like form, at leni 
loses its mesentery opposite the third sacral vertebra, and becomi 
continuous with the rectum at a point arbitrarily but somewl 
indefinitely fixed at the left sacro-iliac joint. 

Surgery. — It will be seen that the eaM;um and sigmoid flexure 
are accessible to opei-utiou irilni-peritoneally through the anterior 
abdominal wall, each at u point nitprnol to and a little above the 
anterior superior iliac spine (Fig. Ri), while the ascemliug »n'' 
descending portions of the colun uuiy be reached retro-peritoneall 
by a transverse or obliijue incision in the space between the thon 
and pelvis, with its centre opposite to a ])oint an inch In-hii 
the middle of the iliac crest (Fig. H6). In an uncertain prop 
tion of ciuses, bovvevei-, a true mesentery may lie {iresent for tlie 
portions of the large intestine, but it is probable that this is fij 
le.ss common than examination of tlie empty or partially emp^ 
gut in the dead subject would lead ns to imagine. A mesenter; 
that does not disap|>ear when the intestine is fully distended 
perhaps not prescul \u wore than one case in twelve. 

The Rectum is 8 or 9 inches in length and extends from the le 
eacro-iliac joint to the anus. It is divided into three portions, the 
first, 4 or 5 inches in length, reaching as far as the third piece of 
the sacrum ; the second, 3 inches long, passing to the tiji of the 
coccyx ; and the third, about an inch in length, ending at the unal 
aperture. The yirst jjortiou is coutiuvvous with the sigmoid llexun 



Old 

-•it 

'I 




THE ABDOMINAL VISCKHA. 



305 



i-'ijf. mi. 




t'if. 140. — Tbc abdontltul vtMimi mivii fniin tlii' left ada (ailupteil fmiu ibr 

model of Uu). 
I. StaoMrli. V. Iliiicui. 

3. Spifn, lU. I'ulvic iwrtion of ti^noiil riv«ure 

'i. Triuorrar iHiluii. ill ooutinuitliiin witli fimt (lur- 

' tion of ict'tum. 

OH' 11. roupurl'* ligaittfiit. 

r>. ^>. i'2, LfMK'r iwtf'ni-M'Utit' liguniimt. 

7. (icit of o;)cfn- 13. Kcniornl VRMels. 

14. Kvctuni. 
A. i^iM-lnlatJuiutiviuw. 16. Uri-nt auoro-uiatu' Ugumu»\ 



306 



THE LARGE INTESTINE. 



and ia^onnected to the back of ilie jxilvis by the same me»SB 
It it characterised by the absence of saccuhitioii, owing lu iJir i 
tributiou of the longitudinal libres of its inunculor cout aruuuil iLr 
whole circumference of the gut, but there is no deliujt* jioinl a_ 
which this change of ommgement take« place. The tcand port 

Fig. U7. 




is fixed to the btiok of the lower half of the sHcrum, and is 
by jK-ritoneuni only in the upper thii-d of jt« anterior surface, the 
lower two-lliinl8 of this surface being intiinalely connected with tbf 
back of the bludder, the vasa deferentia, and tlie jii-ostate,* and in- 
vested by a sheath of reoto-vewcal famna. The third portion "~ 



Fig. U7.— Tlie portal vein aiid its tribiituries (from llenlc). 

I. Gnttro-duodciml vein. 4. Inferior mcwnleric vein. 

'2. 8pliniic vein. •'5. Superior me«eiitcrir vriu. 

■'1. I'oilitl vein. 6. Superior bsniorrlioidBl vein. 

• The proBlstc i» sonietimee regardeil nd ft relation of the tlurd portibiv, ^ 
iranJd in tlii« c«w have b length ol ay a two viu:\\e* uiowis vU foaterinr wall, j 



THK blLK Pinr. 



307 



A» u\A lAmi-whnt 1in<;kwanlH Inawneii tlii' two IovhCpITx aiii, 

iotiiniilrly couiiect«:(l with il, uml has no jivrituiit'ul reU- 

It !» Humiundt<d by tliv exU-rnul >ipliiiict«r just uliovu the 

and hIxivl' tliit ito circular iiiuiculur Ubr(», ben: greatly tliick- 

fonn lli«* inlrnuil tphivcttr. 

tie mucoui manlirauf of tlic intfjtinr and the ilfo-caeal rain will 

Xiuiiineil at a laU-r sl;igc of the iliiwri-tion (p. 330, rt M'/.)' 

? Bile Buot (Fij{, I4:J, 7) shoiilrl l«j tnn.fil up to the liver, 

it will Im- found to cotiiiniMico in ri>{hl and left licptitie diict$, 

rh '' >iu thv traiiaveriv tiMurv uiid uiiit(> to form the 

nnuii ■'•! : thin l« joined iit im acute angle by the duct of 

the pill-blttiider \diiilif), uud becomes the common bile duct or 

ntitetiM rmnvtunii clmlfduchut. The biU- duct ut firiht lien lictwei-n Dxe 

^^Blt> of the lrH«er onientiini to the right of the hepnlic. artery ami 

IPKlftl vein, then jMiMct behind the fimt iNjrtion of the iluudenuiu tu 

Join the jNUicreatic dacl, and op«n into the Mcond i>urlion of tlie 

ienunu 

lie Vena Forts (Kig. 147, j) in fonned to the right of the 

liou line by the junction of the Kjilenic and HUjierior mesenteric 

liehind the u|i[»er binder of the puncreiti, iilMiut an Inch and 

If from it* rixhl eitivmity, anil immediately in fh>nl of the 

«iv«. It id four inche" long, niid imrentlx Ix'tween the U»yer« 

'Mienlum til the tmuHverxK fiiwurv of the liver, Wtween, 

Ici, the bile duct and the hepatic alter}'. It receivea 

tie email goxtric ami cyKtic veino, and like ita iributariea has uo 

^^■hc Bploen (Kig. \i'A, 4) is a Munewhut llattened organ of nviil 

IPPIinc and purjile colour, in-^ujiying the back of the left hy{iOchon- 

driutn. IXn long uxi* U oblique and ronv8]ioncU to that of the lotk 

rib. It \» Httrtched to the greater end of the atoniiK-h by the giuitro- 

•pleiiic uuuoitum, and ii) the diuphl-ngin by the lieno-phrvnic umen- 

lt« }Mtrieltit DUrface in in contitct with the diaphrugm. It« 

it surface iit divided by a ridge into two i)nrt«, tlie jHjslerior of 

th is ujiplied to tin- outer iHuder cjf the left kidney luid «upra- 

capeulc ; while the anterior and larger lieH in cont^ict with the 

the tail of the pancreit'^, and the uplenic flewirc of the 

■1 and pnvtents a hHum jtierceil by the splenic vcMselit. Itn 

■iur Itunirr in UKUully notched, the jmitrrtnr entire, but this is 

jiuvuruilde. Its itpiier atrrmtdj appmuches the spinal column 

[touches the left supra-rvual cA])uule, it« tower ertrtmily reaches 

poatcriuT axillary line and is sup{>ortcd by the coato-colic fold 

eritflncum. Its weight averages »ix ouncci, but varies gTcaUy. 

Tt is cfoza^letelr inreeUtl liy the ^'renter sac of peritoneiun, rxc«\A 



308 



DEEP DISSECTION OF ABDOMEX. 



lit the liiliini, wLiti- the svrous iiitmbrane i> reflectol upon lli*»lfcldir 
vessels, and wliei-e ii siiiall portion of the Ivuser sac iniiy separtt* tkr 
two layere of the j;reater eac ond come into contact with the bam 
.surface of the organ (Fig. 135). 



Deep Dissection of the Aboomkx. 

[The atnniach, ditodentiin, pancreas, and .spleen gliutild now 1 
taken away liy divi<ling the a^pophagti!*, bile duct, and verwU, i 
tile liver should then lie cai-efully icnii>ve<l in unlir tn »«• itl 
ftii-an^jenii-nt of the enj'dnniy liynment. The round an'l fsVifn! 
lif-iinicuts should tirst lie cut and the liver jiuUol dnwn ; hy ciirryb^ 
the knife alon^' the attacJinient to the diuplirn<{ni, the upper liiVt-r^ 
the <i<ronarv ligament will then be divided, as well «> the ri;jht 
left lateral ^i^aineiit.s wliieh jiie funned from it. The vniu ui^ 
mid a )iart cif the liver uncovered by peritoneum will now be exjn 
llie hitler beiti); atUicVied to the diai>hi'ii;<ni by arcidar tig*iie : 
when this is carefully ilivided, the rij^ul nupmremil capsuli- :«nil 
top of the rij;ht kiilney will be broujjht into view. The v»ii:i i 
niutit be cut tliioufjli at tlie ujiper and aj;niu at the lower miir.-iii I 
the posterior surface of the liver, when it will only be nin-e».-«rv ( 
divide the under layer of the coronary ligament (derived chiefly (tt 
the lesser siic of the |)eritoncuui) to reinnve the orgun. 

The viscera should all be jdiiced in a covereil pan, for ezaniiu 
durinj,' the time that the iubject is turned. 

The diaphratjm h Ui be cleaned by *! ripping off thir |ieritoiiciiii 
a.« far as possible in the dii'ection of ilu- niuscuhir fibn-« ; and at I* 
^ame time the inner surface of the tlaji of ubdoniiiml niu-clesi i 
ultacIiL'd .should be cleaned, in urder ti> follow out the fibix-ri i.f I 
troUBversalis. Care must K' taken to a\iiid puucturinj; the diaphi 
und to presen'o the branches of arteiy and nerve runiifvin;,' on 
surface. The crura or muscular slips on fiich .Mde of the 
must l>e cleaned, and two tendinous arches over the ]>soas iiixl 
(|undratus luiiiboruin niuscle.-4 deKned, fur which purpi>.->c it will 
be well to detach one kidney ami tuni it over to the uppositf af 
tenipoiniily.] 

The Diaphragm (Fig. 148) is an arched muscle, concave 
wardh the abdomen ; this concavity is e.xag^eroted after dea 
owing to the fiict that tj^iration is the last act of life. It rises ( 
the level of the fifth costal cartilajje at its junction with the stcr 
on the right side, und to that of the si.vlli on the left. It nritt I 
the back of the ensiform cartihige ; fii>m the inner surfaces of tl>* 
cartilages of the six lower rilis, where it interdigitiites with Hw 
transversulis abdominis ; from the internal and external arcuate h^ 
metits, which cross tlie psotvB MiA i\v\»Lv\Ya,Vv^ \\vvv\««v«icw xivwwla «• 





THE DIAPUUAOM. 

uporlivrly ; «:iil li_\ it" rnira Inmi tin- InmhllT vprtoTiTir And iiitervcT- 

The I cj-lcmiim \h h I'lhniili* ulch (•xli-iiiliii(; 

trum iIj. ■ cif the Unit (oca^ioiiiilly IIh- (<i"'.imil) 

Jaiubar vt.rU'lirri u> liii: tip ^r tli« last rib. It crosses tb« u|>|wr ptirt 




nf tin? quwInitUB lumlNiniiii ; f;'*'i"B attachment atiove !•» tl>o 
lii'i lire* iif the •liiilibni>;iii. iviiil Mnw to tlie anterior lamella 

<ii , lior t>mloii of the triuisvL't>uli« ami to ihr lifcin truii»- 

«Kali» \l'ig. 146, 5). 

Fir. H* rnil<T or aUlimiiiial «iirfiu'e nf ihe ilt«pbnigni (from Wilviii). 



1. Tlar •'Ciitral Iradel uf t]irtrmUnau> 
f«Mitrt'. 

i Til. 1. It i.p >ii<nll|.<t Icttdl't. 

.. (liM mnifnrm rur- 

•^. Ii^ni#*uluni uri'itoliim rvtrrtliiiu 

of 'li' I.fl -i.l.. 
4. Lii untiim liiloiiiuni. 

7. A ' 1 ufM«nm^ fctr Iho 

1(4*1 •I'tiiii' itiii' II' n I' (nci'n- 

•lonul). 
^ Utijfhl cm*. 



0. Fiiiirlh lunilnir vi'fti.'\>ra. 

10. U-ft irin. 

11. Aiirtic upcnln>;. 
I'J. l£«oi>)iiigi-al ii|H'itiii|{;. 

Kl. OpoiiiiiK for till- iiifi'riorTHnainvii. 
14. I'auu iniijniti pusMn;; hencnth 

thi* litcumrntum un-uatuiii tif 

tt:ruiiin. 
lo. QiiiiilriitiH liitiiWuni |iiiiwinj; Im- 

muilh thc'ligiiini'iiliini nnimtiim 

I'ttrriiuin. 
16. Tip of Iii«t rib. 




310 



DEEP DISSECTION OK ABDOMEN. 



Tile liijamentutn arcuattim uUernum is a giuiilar arch runiuni 
from the outer border of the eras over the psoas, to become albicbal 
to the tip of the Hrst or occasionally the second lumbar tnuur«t» 
proc<«B. It gives attachment to muscular fibres above and to lie 
fascia iliaca below (Fig. 148, 6). 

The crura or pillars of the diaphragm ar\»t from the front of 
bodies and inteiTertebral discs of the four upj>er luuilxir verle' 
and usually from a mesial fibrous arcli over the aorta ; the right i 
is the larger, and extendu as low as the fourth vertebra, while 
left reaches only the thin! lumUir vertebra (Fig. 148, 8, lo). 

All the fibres of the dia])hnigm are inieiieil into a ceuLral tendon, 
called from its shape the conii/onn or tre/ml Intdmi (i, 2, 3), hat 
the inner fibres of the crura decussate with one another and funn 
a figure-of-S liefoi* they can pass into the tendon, thus alniodt runt- 
plet'Cly surrounding first the aorta and then the ccsopbagus. The 
right lealltt of the tendon is the largest. The i)ericardiuiu ii 
attached to the upper surface of the diaphragm, partly to the teuilnn 
and partly to the muscular fibres connected with the left leallet, and 
aids in the ujiwunl fixation of the summit of tlie dome. 

Ojteiiiiiijn, — There are three large oj)ening8 in the diaphngm, 
for the Aorta, the tKsophagus, and the ^'enR Cava ; and suull 
orifices in the crura for the splanchnic nerves, one in the left cru» 
for the vena azygos minor, and one in the right cms for the ran 
iizygos major, if this vessel does not pass through the aortic opening. 

The Aortic and QJtophageal openings are fonned by the fibre* of 
the crura. The anterior or (esophogeal opening, which is slightly 
to the left side, is entirely muscular ; but that for the aorta 
be found upon dissection to be bounded by the internal tendinoi 
fibres of tin; two crura, and usually by a fibrous arch between thi 
The aortic opening is strictly speaking behiuil the diaphragm, aa 
is coui[ileted posteriorly by the vertebnd column. 

The u]K-ning for the Vena ( 'am is entirely tendinous. It is moic 
or leRs ([uadrilatcral (Joramcn nuadratum), and is situated in iiti 
right division of the conlifonu tenilon. I 

Tliriiugh the aortic orifice pus.s the aortii, the vena azygos uiajuq 
and the tlioracic duct : through the o:in>pltiiyeal ojiening, the asei 
phagus with the two pneumogastric nerves ; through the carm 
opening, the vena cava inferior (which is firmly attached to Urn 
margins of the apei-ture), and also a branch of the phrenic nervM 
The greater and lesser splanchnic nerves pierce the erus on eadl 
side, and the lower heiui-azygos vein passes through the lefl 
cms. The ganglialed cord of the symjiathetic is continne<l into thi 
abdomen from the thorax beneath thtt ligaaiculum arcuatum iuteq 



hUv 




8YMPATHCTIC NERVE. 311 

nuin. The eoBUhxifhoid ipare on each Hule, lietwecn the Rtenial 
and costal origins of the muscle, traiiiiniit.s the «up«^ri(>r epi{i;«stric 
Teaaek and some celluhtr timuc. It in soinetiiiutK the neat of ii 
hernia. 

Action. — The iliaphiatan u eHfieiitially a muRclc of inspiration. 
It acts partly by the Mtrai(;htening of its curved fibren, mt nugnieiitinK 
the space between it and the lower part of the clieRt wall ; and 
partly by elevating the rilw to which it u nttacht><l. Itti tendon 
probably does not descend to any material de^^H*, but it opposes a 
pasrive resistance to the upward pressure of the abdominal viscera 
daring the contraction of the abdoniinul niuscles. The diaphragm is 
titpplied by the phrenic nerves from the cervical jdexus, which, after 
traverung the thorax, pierce the tibres of the muscle and are distri- 
buted principally on its under surface. Its arteries, the j^rrmr, 
from the abdominal aorta, on the under Kurfure, and the mu*culo- 
pkrenie and coma nervi plireniri fmiu the internal mammary, 
anastomose with some of the inten-ostal arteries. The brtmches of 
the internal mammary will )>e si-en when the npper surface of the 
diaphragm is dissected with the Thorax. 

[The vessels and muscles of the alNloiiiinal ciivity an* now to be 
eleanetL Anmn<l the uorta and its bnuiclies will Im> found the sym- 
pathetic nerve gi>ing off jdexiisen to the s<'vend vessels. The gn-ater 
rt of this may be removed, bat the <rreiit splanclinic nerves should 
traced from' the ]M>iuts where they jiierce the crura of the dia- 
phrasm to their terminations in tfie stnuiliinar gaiiiflia. These 
ganglia are large masses of a pinkish colour, HituuU><l on each side of 
the aorta cluie to the diaphnigui ; the ri^ht liex IxMU-iith the vena 
cava, and it will therefore be necessary to tuni down tliii vessel for a 
short distance in order to expose it ; thev riomdy resemlile lymphatic 
glands in a])peanmce, and ate connected liy numerous ner%'es sur- 
rounding the cocliac axis and constitutin;; the solar )ilexus. The 
({angliated cord of the symiNithetie on each side of the vcrtebne is t<i 
be pteservetl. The vena cava inferior (a )iiece of which it will be 
remembered has been removed with the liver) is to bi- clenni'il, and 
care must lie taken not to cut otf the i-i){lit s]H>nuiitic vein on iU 
anterior surface. The vein may lie xecured in its ]ii'o|ier jmsitiou 
with a pin if necessary. The kidneys and su]ir;i-reiial aijiKules are 
to be dissected and the vessels k""<K t" each <letin<il ; un<l the 
spermatic vessels should be trace<l <iut.] 

Bympathetio Nerve. — On each side of the aorta and close to 
the erura of the diaphragm will be seen a jiinkish bmly of a some- 
what ciesceutic form, called the semilunar ganj^lion (Fi^. 143, 12), 
and into it may be trace«l the great s])lanchnic nerve from the 
thondc ganglia. 



312 



DEEP DISSECTION OF ABOOMKN. 



The Solar plr^tut is formed by fibre* cnjwing In.nii one diinNi;;.! 
gitngliun to the other, nrouiid the cadiac axis and superior iii>"i 
tcric artery and between the supra-renal capsules, and reieivn 4J 
linvnch from the right pneumogastric. Its continuation, the noriie^ 
jiUxu», will liave been more or less seen in cleaning the aotU, Midi 
also the seeondary plexuses derived from it and distributed ujioii lit 
several bnuiches, vir.., the phrenic, gastric, hepatic, «plenir, aui»r)ii 
mesenteric, supra-renal, renal, spermatic, and inferior uie-^iil'' 
plexuses. In addition to the great splanchnic nerve, the le 
gjilalichnic nerve may, in a favourable subject, be traced into tV 
Bolur ]>lexus, and the third or renal splanchnic nerve into the rrn 
plexus. 

The Abdominal Aorta (Fig. 149) is the direct conlinniUinn 
the thoracic aorta, and I'ejiches from the lower liorder <>f ihn I»*l' 
dorsal to the fourth luinbui' veitebrn, whew it divides into tlw tw" 
common iliacJi. It i." enshealhed by sul>peritoneftl connective t:- 
in which are lymphatic ghiTids and nu)re or less fat ; luid is ■ I 
invested by the solar luid aortic sympathetic jilexiwes. It w ■••. 
in front by the liver, stomach, transverse colon, intestines, oii'i j 
toneum, luid, in more immediate contact by (1) the paiictvas, wl(| 
the splenic vein neai- its ujiper border, (2) the left renal vein, fj 
the transverse duodenum, and (4) the branches which spring fr 
Its anterior asjiect. Hehiuil are the bodies of the lumbar vertcL 
and their liganumls, and the left lumbar veins. To its rigM is I 
light crus of the diaphragm, and the vena cava lies in clone cont 
below, but is separatwl from it above liy an angular inteispnce ; 
ileeply place<l between the upper part of the aorta ami the rig! 
cms are the recept^iculum chyli and thoracic duct, and the ven 
nzygos major : the gi-eat splanchnic nerve nuiy cither nin thniu;{ 
the aortic opening or jiiorce the right cnis. To the U/t are the li^ 
gaiigliated cord of the sympathelic, t)ie left crus of the dinphrng 
the splanchnic nen-es, and, pcrliajw, the commencement of the vea 
luygos minor. Its point of bifiirciition, though often in the niiddl 
line, and occjisionally a little to t)ie right side, is usually a Hid 
below and to the left of the umbilicus, above which point it Mu»y ' 
readily compressed. 

Surgery. — The abdominal aorta has been tied inimediatdv bIx)^ 
the bifujcation for iliac uncuri.^'ni, but without success. It may 
reached either by a median incisinn jiroloiigcd above and l»-low it 
umbilicus, as in the original oj)eration of Sir Astley Coojier, tl^ 
peritoneum Kdng necessarily opened in front, and agiiin !»t tM 

iioint of ligature ; or by uu inci.sion at the side, similar to that {m 
'g&twe of the oninii.'n iliac arlety ViVkV, Vekf^tt, toU<>wv:<i by {utrtia 



THE ARIXIMINAL AORTA. 

Filt. U9. 



ais 




Ftg. 140. — AInKimiiiiil umlii niiil vetm cuva (IVotn HenU), 



p, ni>p»tir v«n ("Ut). 
I'hmuf urU'riwi. 
VitM c«Ta. 
O'T^linr nnim (rut). 



itrtery (lut). 



Ih. Ki'liiil vrin. 
I V. ItrOJi J urtrtj. 



111. I*lt aiiciTnnlic vr««l«. 

11. Utght iiiotrr. 

I'i. Inii'riorrooi'iiliTic urlmj. 

!•). I!i)rlit •periiiiitio will. 

II. A : ■ . ' rv. 

1.5. !■ 

17. (.'.HIIIIIiHI lililt- Vl-ill. 

IH. Miildli: >iac ml iirturv 



314 



DEEP DISSECTION OF ABDOMEN. 



(letftdiment of the unopened peritoneimi. if r. Lane proposed to tffU 
the li}j;uturu above iiiBtead ol below the origin of the inferior meiKii' 
teric nrtery, in order to jneserve the iiiiastomoaes of that vea-eL 






The Branches of the ubdominnl aorta are — 1. Phrenic or 
phrugmaiic. 2. Coeliiic oxis (dividing into gastric, hepotic, 
splenic). 3. Superior nieiM-nteriv, 4. Supra-rcnal or capraLir. 
5. RenaL 6. Spermatic (ovarian in female). 7. Inferior meacn- 
teric. 8. Middle sacrnl. 9. Lumbar arteries. 10. Comniou iliaca. 

The Phrenic arteries (Fig. 14!), 2) are two small branches, which 
arise close below the aortic ojxiniiig in the diaphragm, either fr( 
the aorta or from the cadioc axis or other branchea. They 
on the under surface of the diaphragm and luiostomoee with oi 
another, with the f.U]>erior phronii; and inusculo-j>hrenir of 
internal mamniory artery, and with the lower inte^t■ONtul^<, 
supjilies also a bniuch to the stipra-renal capsule {^superior cnpnti 
and small twig>t are given by the left tu the a'^ophogus, and by 
right to the vena cava. The two artorie.s may spring from a si 
trunk. The right rein opens into the vena cava, the left into 
left renal. 

The Cceliac Axis (Fig. 149, 4) is about half an inch in length. 
It arises from the front of the vessel above the upper bonier of the 
l>anoreas, opjjosile iho disc- between the last dorsal and tirst lumbat 
vertebne, and divideti ut once into the gastric, Itepatic, and sj 
arteries (v. ]>. 293). 

The gastric and i^jdenic tviiis terminate in the vena jiortie, bl 
the hepatic veins, which receive the blowl from the vena port« 
well as from the hepatic artery in the liver, Ofien into that poi 
of the vena cava which is embedded between the lobus Spigelii 
right lobe proper of the liver. 

The Superior Mesenteric artery (Fig. 149, 6) arise.s from 
front of the :irirta lielow the cceliac axis and behind the pane 
opposite the tirst lumbar vertebra ; it runs downwards and forwi 
between the pancreas and tiwnsverse duodenum, and with its vi 
is »urroun<le(l by the lower procos.^ of the head of the pancreas. It 
supplies nearly all the small and half the large intestines by means 
of its inferior jmucreatico-duodenal bninch, vasa intestiiii ttui; 
and the ileo-colic, eolica dexlra, and colica media arteries (Fig. 13 
Ita tviH opens into the vena_poTtie. 

The Supra.-renal arteries (Fig. 149, 7) arise oppodte the 
lumlmr vertebra anil pass, one on each side, trnnsveisely to 
supra-renal csipsules, the right going beneath the vena ciiva. 
^e fcctus they arc as laige as the renal arteries. In addition to 




BB&NCHES or ABDOMINAL AORTA. 8 15 

this artery {middU eaptular), the ctt])iiule w mtpplicd hy a brunch 
b«m the phrenic (superior) and one from the renal artery (inferior). 
The right vein enters the vena cava, the left the renal or phrenic vein. 

The Renal arteries (Fig. 14U, 9) arise on each side of the aorta 
immediately below the capsular arteries, a1)oiit half an inch liclow 
the superior mesenteric artery, and opinwite the lower Ijonler of the 
fint liunbar vertebra (the ri(;ht usually a little lower than the left). 
They run transversely to the concave border of the kidney, the right 
going behind the vena cava. The aorta bein;{ a little to the left of the 
middle line at this point, the ri}{ht renal artery is neci'ttwirily slightly 
longer than the left, while, owing to the jiosition of the vena cava 
on the right of the column, the right reiuil vein is much shorter 
than the left. The renal artery, after giving oif a HniuU inferior 
eaptular twig, breaks up into three or four bnuiehes just as it enters 
the kidney : one or more of tlutse may (viss in front of the vein, and 
ooeaaionally a branch nuy run liehind the ureter, or may i>ier<re the 
kidney above or below the hiluni, but w a rule the relation of the 
pazta at the hiluni of the kidney is (1 ; Vein, (2) Artery, (3) Ureb-r, 
from before backwards. An additional rennl art<-ry not unfre- 
qnently arises from the lower i>art of the aorta, or from the common 
Uiac artery, and occasionally more than <ine such v>-.hsi-1 is ])reM-nt. 
It is important for the surgeon to lieur in mind tbesu and other 
poaaible variations in the arterial supply in o]ier.itions uisin the 
oigan. The renal or emulgent rrivt o)H-n into the vena cavu, the 
left crossing in front of the aorta imme<Iiately lielow the su]H-rior 
meaenteric artery, and receiving the left s]K-niiati(-, phrenic, ami 
aopra-renol veins. 

The Bpermatio arteries (Fig. I4!(, 10) are two long slender 
branches, which arise from the front of the aortu about an inch 
below the renal, and pass downwards behind the jHTiloneum to 
the internal abdominal ring and through the inguinal canal to the 
testes. The right courses obliquely over the vena cava (sometimes 
behind it) and each crosses the i>soas, the genito-crurul nerve, and 
the ureter, and near Pouiurt's ligament the exti-rnal iliac vciwels ; 
then entering the internal inguinal ring to the outer side of the 
deep epigastric vessels, traveises the inguinal canal, to emerge at 
the external ring and enter the scrotimi. In tltr fmmU the .t^H-rmatic 
arteries become the ovarian, and pas.-) into the ]H-lvis to ramify in 
the broad ligament of the uterus (Fig. 1 (>(i, i }. One wmall twig 
•coomponies the round ligament to the inguinal canal, another ruiM 
along the Fallopian tube, and a thinl Hup]>lies jiart of the utcni.i, 
anastomosing with the uterine branch of the internal iliac. 

The spermatic vehu form a plexm around the arteries (pnnipint- 



31G 



DEEP DISSECTION OF ABDOMEK. 




Jurm plfxiis). Tliey t4ike ii iliffei'ent courso ou the two tides, tlu 
left ojK'tiiiig at n riglit aiigli' intn the left rennl vein, ami Iht* n^lil 
niniiing obliquely into the vena cavii. Thin arniiig«npnt i» laiil lo 
iicconnt ill part for the more frequent occurrence of ' voricocelr 
on the left side, hut iJr. J. H. Bvintnii, of Philaileljiliin, funiishr* 
hetter explanation by Jeinonstrating the existence of a valv« at i! 
• aval orilice of the right vein, while there is none at lli 
of that of the left side into the rennl. The left vein, n. 
liable to conijiresKion by Rccuiuuhtte<I fieces in the sigmoid lluure, 
'.vliich lies in front of it. 

The great length of the s|)ennatic arteries i* explained by tl 
fact that the testiclcH were originally in the abtlomen, opjiosilc tl 
point wheiv the arterieji aiise, and that as they desrended 
vessel* neceiisarily lii'cimie elimjiutefl. 

The Inferior Mesenteric artery (Fig. 149, 12) arise* op] 
the tliiiil lumbar vertebra, a little to the left of the middle of 
front of the aorta, and supplies the lower half of llie large in; 
(v. |i. •liii) by its left colic, Kignmid, and suiierior hseinorrhoiiUl 
bwnche.-<. Uk itiii o]>ens into the sjilenic vein. 

The Middle Sacral (mrml mirln) (Fig. 14!1, 18) is a <iuail 
branch arising at the biftircution of the aorta, ami piusiug do«nt 
into the pelvis along the middle of the sacrum. It aiiaslom'j 
with till- liil<;ral sacral braiidtes of the internal iliac Mrterii-s. Tl 
corres]K>niling m;i opens into the left comnicin iliac vein. 

The Lumbar arteries (Fig. 14i», 14), usually four in number 
each side, ui-ise in a double row from the back of the uorta, 
pass transvei'sely, clos<> u]hiu the vertebrte, Wnearh the ]isiiits ai 
the gangliated cords of the symijathetic, and on the right sii 
beneath the \ena cava. The u])per arteries also j^ss under 
crura of the diaphragm, where these bridge over the nnnv>' 
jMU'tions of the bodies of the vertebra;. Only small portioo" 
these arteries eiui \w seen at jjre.'.eiit, but when followed out ei 
will be found to divide into an anterior and a posterior bmne 
The tiideiior blanch runs lietween the abdominal muscles, to sup] 
them, luiil to anastomose with the lower intercostal, epigastric, ui 
ciivumllex iliac aiteries. The tii'st anterior bniuch usually p;is 
in front of the quadratus Iiinibonini, the others Ijehind it. Tl 
poderwr branch passes between the transverse processes, sulxlivid 
into muscuhiT to the erector spina*, ami sjiiuut to the vertebruJ cii 
through the intervertebral foramen, the latter vessel supplying i 
bony and ligamentous walls of the canal, the membranes of the coi 
and the coixi itself by means of a long twig which runs along the 
nen'e I'oot, The lumbar rcinn, three ot fowt fov cfttliivde, oyen into 



Ir' 

1 




fOMMON ILIAC VESSKUS. .'{17 

the vena vara. They are connected oi>]x>8it« tht> traiiHversc ])roceii8ci( 
of the vertebnc by a vertical vemel, the aiuvniliiuj lumhtr rein, which 
fumis the radicle of the a/.y}^M vuiiiH. 

The Common niao Arteries (Ki);. 14!i, i6) ai-u the diivct i-nn- 
tiniiations of tin- alxliiiiiiiinl uuria, uiid e.xU'iiil frniii tin; bifitn-ation at 
the fourth hiniKtr veitebni to the liiiii)K)-.-<iu-ral articuhiti<»i, whent 
each divider into thf t-xtenml and internal iliac artiTi«-'<. Tlic ri^bt 
common iliiw is usually a little lonj^cr than the left ; and the nda- 
tiona differ on the two xides, im-inK, ]ii'in<-i|ially. In the fai-t that the 
two common iliac i-'Ihk unite to form the vena cava on the ri);lit 
ride of the vertebral column. l{4itli artorit-s rc^l on the vertebral 
column, coveretl in frunt by the ]ieritoneum, and are UHually ci-owed 
near their termination by the uret^'rs, but the Ir/t is ci-oHsi-d in 
addition by the rectum and su]>erior hivmorrhoidnl vi-sscis, and the 
right by the termin:itii>n of the ibium and the lowi-^t branch of tin- 
•aperior nie>enti.-ric artery. The h/t artery rc.»ts a<,'aiMst tin- jisimih 
magnuH, n-hile tin- riijht art4.-ry lii-s ujHin itii own vt-in U-low and 
croHReH the vein of the i>|i]>oMite nide alK>Vf. Tin- only hntiirhis IVoni 
the trunk's are Kmall twi^ to the iliacnx nnisclo and to tiie ureter. 

Common Ii.i.vc Vki.ns. — The If/i common iliac vein will be kim-u 
to lie to the inner Hide of itn own artery, and then to ]iiixx bt-ncath 
the ri]>ht artery to reach the vena cava, whilst the riijlil vein is at 
first behind and then to the outer »idc of the rijiht iu-tery until it 
unites with the left. Thu^t iNith the veins lie to the ri;;ht of their 
re!<i)ective arteriei*, and the cimnnencenient of the vena cava is imme- 
diately to the rif;ht of, or Mometimes even slightly liehiml, the ri;;ht 
common iliac. They ix>ceive the lateral Ma<-rid and ilio-lumlxir \'eiMs, 
and the middle sacml vein enteni the left comnum iliac. 

The Vena Cava Infisrior {Vin. W.i. \) lies ensheatheil in 
nubiicritoneal tinflue to the ri(;ht of the aorta. It is in close relation 
to it below, btit is seiMirated from it by an nn^nlar interval above, 
and there lieN in a more anterior jdiuie. It is formed by the \i\nr- 
tion of the two common iliac veins on the ri){lit of the tiftli bunbai- 
vertebra, ainl kee|>i« to the right of the vertebral colunui un lii}{b as 
the liver; where it iKWues somewhat forwaiil, (•nteriM<{ a deep j,'>'oove 
(occasionally converterl into a cunal by a 1irid;{e of he|iatic sub- 
stance) between the lobus S)>i<(elii auii the Tv^Ut lobe ]ir<i|ier, and 
receives the hepatic veiuM ; finally it n^aches the ijuadrilateral oju n- 
ing in the diaphraKni. In frutit of it an- the ]ieritoneuni (with the 
foramen of AVinxlow), the diUNlenum, the ]Kincreas, the liver, the 
portal vein, and the right spermatic vein. lUhiiid lie the vertebral 
column, the right crus of the diaiihragm, a portion of the ri<;lit 
supra-renal capnule, the right cai'snlar. phn-nic, n'i\al, svv\>viv-vei\»\. 



318 



DEKP DISSECTION OF ABCOMeN. 



and liuulmr art-cries, and the syinpathetic chain of ganglia, besiiJi 
occLOHionnlly tlie lirid^'e of lu-patic «ul>Btancc {yontieuliu) mentinna 
above. To the ritjht, and in close contiguity, lie the right kiilna 
and ureter and the greater part of the supra-renal capsule ; to th 
If.ft, the aorta, the thoracic duct, the coninienceraent of the v« 
a;£ygc>s major, ami the solar plexus and right semilunar ganglia 
It receives the lumbar, right spermatic, renal, right supra-txrnal, a 
right jihrenic veins, and as it passes through the liver the la 
liepalic veins open into it : thus it returns the whole of the Wo 
of the alViomen and lower extremities to the heart. 

The External Iliac Artery (Fig. 166, 3) reaches from the {oil 
of bifurcation of the common iliac to Poupart's ligament, where 
becomes the femoral, its direction corre8|)onding with a line <!«« 
from the umbilicus to a jioint midway between llie symphysii puh 
and the anterior superior iliac spine. It passes along the bnm ( 
the true ])elviH, and upon the psoius muscle, invested by a pnicest i 
subperitoneal tissue, which includes both it and the vein, anJ mil 
l>e removed in order to exjiose them. The crural bn\nch uf ih 
geniu>-i;ruinl nerve lies close to the nitler tide of the artery, and 
genital branch of the miine neiTC, as well as the spermatic vmae!) 
and deep ciR-umllex iliac vein cross in fruiit of it near I'uuport^ 
ligament. Occasionally the ureter cro8si.'.s the upper part of 
artery. The rrin lies to the iniifr side of the arterj- in the who 
of its course upon the left side, but is Ixmeath its upper port on 
right side ; and, close to Poui>art's ligament, the rag drfemin or niaii 
lifKiinnit hofiks arouud the epigastric arterj', and dcscemiH into 
|)elvis to the inner side of the external iliac trunk. 

Like the aorta and common iliac arteries it is ensheathetl by nil 
peritoneal connective tissue, and three comjiartments niny bo 
monstrated in the .sheuth as well as in that of the femoral artcr 
with which it is in continuity : — an external compartment for th 
artery, n miildle for the vein, and an internal, leiss well dctined, fcl 
u chain of lyui]ihatic glands ami vessels. 

Uranrlirs. — The ileep epigastric and the deep circurotlex ilii 
arteries are usually given fiff just above Poujiart's ligament, ba 
occasionally are found on a level with the ligament, or even sprini 
ing from the common femoral IhjIow it. 

The EpifjnslrU artery passes inwards and upwards imtnedtat«I| 
outside the peritoneum, and pierces the fascia transversjilis to entd 
the rectus muscle at its posterior aspect, to which it has 
already tra<'ed (p. i72). Its relation to the vas deferens and rour 
ligament is mentioned al)Ove. 

The l)rancheK of the epiga-sUvc are ptihit U> X\\6 Wik of the ^vh 




THE ILIAC ARTERIES. :n9 

bone, erematterie to tbe conl, and vnueitkr. An nlmoniml bi'anch 
of large size k frequently foiuul ctmiiiiiK otf from tlie cjiij^'ostnc cIoRe 
to its origin, and descciKling into tho \n-\vU ; thix im tliv obturator 
•iteiy, and its im])ortant relations to the neck of a fvniorul hernia 
have been already described (|>. 1 i!}). The ipiijiiiiirir vrin joins the 
external iliac vein. 

The Circumflex lliar artery tukeii u counic oiitwanlx along Ponpart's 
ligament, and lies at titst ininiediutvly outfiide tliu jx-ritoiieuni. It 
soon, however, pierces the transveritiiliH fitsciu and muscle, and runs 
along the crext of the ilium lietweeii the muscles, to HnaMtr)mose 
with the ilio-lunibar branch of the iiitcnial iliac, with the last 
lambar, and with the sujierlicial circumtlcx iliac arteries. The tvin 
has been seen to cnisii the external iliac artery an inch alK)ve 
Poupart's ligiunent, to open into the external iliac vein. 

Surgery.- -Tlie oi)eratioiis of tyiii;; the iliac arterii-s cannot W 
conveniently practised on the subject, as the iiiuscli-s of the alxlonicn 
would lie necessarily dauia;;fd. The lullowiii-; is the usual iiiiKle of 
proceeding :— 

To tie tbe Kxtemal Iliai; ariery, a liuiated incision thitie and a 
half inches long is to U; niiule nliout an inch above ami ]>arailel to 
Pnnpart's li-{anient. The tendon of the external oblii|iu- and the 
fleshy fibres of the internal obliiiue ami tninsveisidis muscles are to 
be dividetl in the same direction and to tlie Siimc extent, and it is 
nsoal todivide the transvermlis on a director, to avoid tlu' possibility 
of injuring the {leritouenni. ('are must also be taken not to wound 
the epiffastric artery. The fasciii tnmsversidis, now exposed, is to l>e 
dividetf on a director and the ]ieriton<'Uiii is then to be carefully 
■tripped up from tbe iliac fossa and tuiiKril tiu'Waiti with the viscera, 
the ureter and spermatic ves-els gener.illy adlierin<,' to tin- membrane 
and lieing then-fore drawn out of the way. 'Die finj^er cun now reach 
the inner bonier of the psitas, at which the artery can be felt, but 
the subperitoneal sheath must lie <'ai'efully (i])eiied befoiv the needle 
can l>e passed lietweeii the vein and the artery. The vessel should 
lie tied as nearly as jiossible midway iK-tween the origins of the 
internal iliac and e]iigastric arteries. 

The Internal and Common Iliac arteries may b(> tied thniugh 
a similar incision prolonged to a lenj^th of alHiut (Ive inches, or liy 
one of similar length placed so that its centre is opposite the anterior 
saiwrior iliac spine. The steiM of tbe ]ir(iceediiig are tlie same as 
those for tying Uie external iliac, but the ojierations are nion^ aniuous, 
owing to 'the greater depth of the arteries and the eonsei^uent 
difficulty in reaching them. A din*rt transiieritoneul ojiemtum is 
easier and safer, and is often preferred even for the ligature of the 
external iliac artery. 

When the ezterval iliac artery is tied, the circulation in the lower 
limb ia earned on principally by the iiitenial iliac, the bm,ud\ea ot 




320 



DEEP DISSECTION OF AUUOMEX. 



which ({{luteal, sciatic, aiiij ciliturator) uiiustoiiiose frcoly with hiandi 
of the prfifundii leuiuiis. In addition, tlie ftniixtiiiiiosjes lietwccu tl 
uptgusti'ic and tiie iiiteinal luurunmry hiiinch ut thu siilnluvi^in, 
lii'twt'cn tht eircunitlex iliac and the lumbar aHerie*, iKrcome gn. 
devi'l(j]ied. Weif tlie inUrnnl iliac tied, u ittum ciirnnit wouU 
estjiblishrd fioni llie prolunda feiiiuriji to the branches Ix'ful 
tioiieil, whiUt the viweliil braiwlieu woulil receive their bliMxl ' 

l-'iR. l.K). 




anaitomoseK with the vi-sseli* of the iij)|>osite side. When the ctnnmi 
iliac is tied, the circulation in the lirtili deiieuds muinty upon til 
int<'nial inammnry and e|n;.'ai=tric, uideif by blood brou;'ht circuitou^ 
fniin the o|>|jtvhit.e iiiti rii:il iliac to Ihnt of the same hide, and thenj 
t<) the profunda feuioriii. Tlie middle suial artery would also for^ 
a direct comnninicatiou belHecn the aorta and the lateral 
branch of the internal iliac. 

The Kidneys are a ptir of bean-iikapeil orgiuiH, each meaeuringali 



Fig, loO.— Uiiigmin shomni^ relatiou of kidncyji, «upm-rrnnl bodiei*, and 
spleen (\V. A.). (From ilorris's Synteiii of .Viiitlomy.) 

9, Duodenal nrcit (nan-peritoocal). 

10. C'olie area of spleeu. 

11. Mr»o-cfilic area. 

12. Colic urea (non-peritonral). 
14. Mcso-colic area. 



Cttval arcii. 

(iiuitric area (pcriloucal). 

3. Heputic urea (non-iwritotieid). 

4. Gastric iireii of splei'M. 

5. Duiidenul area (iiou-peritoneal). 

6. Splenic- urteiv. 

7. lleputii- nri:« (peritoneal). 

8. i'anoreiitic nreii (nou-ii«riio\H'»l') 



16. Ttetcr. 
IH. Aorta. 
10. N'MWBavtt. 




THE KIDNEY. 



321 



4| inches in length, 2j inches in breadth, ami an inch and a quarter 
in fhickneas, and veighing about 4^ ounces. They lie in the hypo- 
chondriac, epigastric, lumbar and umbilical regions (see p. 278) and 
•le placed behind the peritoneum in a kind of lymph apace in the fat 
bearing subperitoneal tissue (Fig. 13S), opfmsite the lout dorsal and 
three upper lumbar vertebne, the right usually lying about half an 
inch lower than the left. The long axis of ench i« directed down- 
wards and outwards. Its antrro-exttmnl or vinfmil nurface is directed 



Fig. 151. 

OUTLNC OF I2U Ra 




Kig. 162. 



0, '-, 



"1' ^s 




HI -W 



ontwards and forwanls, its jmMrrtt-inUnuil or pirieUil nur/ace look» 
backwards and inwards. Its (ivtrr lioriirr, representing the angle 
of junction of its two surfaces, is narrow ami convex. Its i«ji«r 
border, looking obliquely inwanls. for^vards, ami a little downwanls, 



Fig. 161. — Diagnin of leUtiona of the posterior surfico of the kidney (W. A.). 
(From " Morris' System of Anntomy.") 



TtansvetM pioeeaKa of the first 
and Moond lombsr rertebnc. 



2. Lino indicatini; o\iler border of 
quadrutus lumboruni. 



Fig. 162. — Two forms of the renal duct (from 'Wilson). 
A. Calyx. Or- Ureter. 



P. PdiriSL 



I. Infundibulum. 



822 



DEEP DISSECTION OF ABDOMEN. 



is convex above anil below, but slightly concave in its ini'Mle th 
and fissured by the hilam. The up)>rr ejritemity ia roiimleii, i 
eupporta the supra-renal body, which enci-oachea also upon] 
anterior surface and internal bonier. The foww rjirrmtlii, 
rounded, lies farther from the median j)laue than the iijijifr. 

The hilum is a tslit-like aperture in the middle of the 
border of the kidney, bounded in front and behind by two jm 
neut lips. It forms the entrance into a deep depression nr oiH 
the nntu, at the bottom of which lie (1) the renal piipillse perfon 
by the openings of the secreting tubes, (2) the apertures 
jnittin)> vessels and nerves to the on^an, and (3) the nttachnicotal 
the ' calices ' of the main dnct, each embracing one or two nf I 
pui)ilUB (Fig. I(iO). The kidney may in fact Iw regixnled 
hollow organ. 

Ilelatwiis (Figs. 150, IW). — hi front of the right kidney are I 
right lolie of the liver, the second stage of the duodenum, 
hepatic flexure of the colon, u branch of the colica dextni 
and more or less of the parietal peritoneum on the inner gide 
the latter. In front of the left organ are the stomach (with 1 
peritoneiiiu of the lesser sac), the sjdenic artery, the jmncrea*, i 
the splenic vein, the splenic flexure of the colon, the {* 
peritoneum, a branch of the colica sinistra artery, and the apk 
(at the outer border). Behind both kidneys are the tliaphntgm, I 
])soas, and the anterior laiuelln of the transvei-salis tendon leove 
the qnadmtus luiiiUorura), M'ith the re.-spcctive fa.-»ci!e of 
muscles, and the Inst dorsal, the ilii>-hypogastric, and the ilio-ingoid 
nerves. The diaphragmatic area is generally laiget »n the 
side, and may be considerably increased on either when the euli 
arcuate ligament passes to the second lumbar transverse 
instead of tlie first. 

The relations of the vessels and duct in the hilum have 
already given (p. 315). 

The Ureters (Fig. 149, ii) should be traced out. Thty^ 
about a foot long, and will be seen to lie in a sheath of sub 
neal tissue over the psoas muscles, passing behin<l the sp 
vessels, and, after crossing the common or cxlemal iliac aiteiT, I 
disappear into the ])elvis, where they will be afterwaixls triced U>i 
bladder. The right ureter runs behind the second stage of tlie <il|| 
deuum, and lies close to the inferior vena cava. In the female t 
tubes ajjproach the sides of the cervix uteri, and lie in contact ^f 
the up]ier jiart of the vagina, crossing it obliquely to reach the 
of the bladder. The proximal extremity of each ureter liepi»i% , 
eight or nine short lubes ca.\leil caUcet, ■viliKh surround It^ 



SUPRA-RENAL BODY. 



323 



papillae at the bottom of the fiiiua. These join with each other, 
with Of without the ijitiTvcntinii of nhort jmssages called infundi- 
bula, to form usnally two tuliea, the vpper and Icictr jjelret, and the 
BnioQ of the two pelves constitutes the cominun jit/i id rntalit, which 
generally narrows to the size of a goose-quill, and becomes the 
HBrtfr proper (Fig. 152). 

The Supra-renal Body or Capsule (Fig. 1-49, 5) is a small 
yellow boily, tioniewhat rej^mbling a cocked-hat, renting upon the 
upper end and inner lx)rder ul' each kidney, and lying against the 
cms of the diaphragm. The vessels to it should be traced out, and 
one kidney and ca}ii<ule are then to be removed and put aside with 
the viscetn for oftet^exaniination. 

The riijlit supra-renal Wly is iriangidar in outline, and in 
contact anUriorly with a special impression at the back of the right 
lube of the liver, below tiiis with the peritoneum and a small piece 
uf the duodenum, and is overlapped along its inner border by the 
infriior vena cava (KoUeston). The left is covered in front by the 
peritoneuju of the lesser sac, which separates it from the stomach ; it 
it in contact externally with the spleen, and e.\tend8 along the inner 
bolder of the kidney as far as the hilum. It is crescentic in form. 

[Tlie kidney 1>eing removed nr turned out of the way, the fascia ( 
^•jvtTiiit; the i>soas, tjuiidratus hniilioiuni, and iliitcus are to Ije ' 
defined, and afterwards those muscles are to Ite cleaned ; all nerves 
paming out of tliem l)cing carefully preserved.] 



The anterior lamella of the posterior tendon of tbetransversaliB 
abdominis muscle {v. p. 262} will be found to lie in front of the 
qoadnLtus muscle and to ]ia88 inwanis to the ti[is of the transverse 
fnctmei and to the intertransverse ligaments ; it is connected 
above with the liganientuni arcuatiim externum of the diaphragm, 
•nd below is attached U< the iliac crest and ilict-huubar ligament. 
It is covered in front by the f<ucui truntverialis. 

The fatcut iliacn, or ilio-p.soiui fascia, ensheaths the psuoa and 
fliocus. The fnuiit iirrr tht piuMUi is attached to the lower edge of 
tbe lignmentum arcuatum internum of tlie diapbragni, and to the 
trertrbnc from which the muscle takes its origin, and joins the 
iwcia over the iliacus )>elow. It is owing to this fascial sheath 
that " p»o«.» abs<-es8," tiic result of spinal caries, is conducted along 
the psoas muscle to the inner side of the thigh. 

The faicia covering the iliacus interniu muscle is attached alxjve 
to the inner li)) of the iliac crest, and is continuous below with the 
Ciscia orer the psoas mognus. The conjoint sheath should be traced 




;J24 



DKEP DISSECTION (»K ABDOMEN. 



I>eueath Poupail's ligament, wlitre it jiiiases beliinj tlie slieatb 
Cemoral vessels to reach the insertion of the inugole (r. p. 131)). 

The Psoas Magnus inuKcle (Fig. l.iS, 6) nrises by tire 
from the sideif of tlie iiiterverlebii\l disc* between the last Joi 
wid all the lumbar vertebra;, anri fi-om the ndjnoent ])art» of 
bodies and roots of the transvers^c iirooi-SLses of these vertebnt : 
between these slips from a series of tendinous arches croeini; 
constricted portion of the bodit-s of the four upper lumbar verteb] 
The muscle passes alon^; the border of the true pelvis in close 
lion to the iliac vessels, and disa]>poar? beneath Poupart's 1i{,'niDi 
to 1)6 iniertfd by a tendon into the aiiex of the lesser troclmnter 
the femur. 

The Psoas Parvus (Fig. 1 ■'>:), 4; i.<i a small muscle occasional 
fovmd upon the front of the p.->oa8 niiignus. It arinfg in front of th?^ 
\ipjXT hlip of the psoas magnuti, fium the bodies of Ihe last do^i) 
and first lumbar vertebra', and fi'om the intervening disc, uiv 
in a long tendon which is innnlnl into the ilio-jicctincal enir. 
and part of the ilio-pectineol line, and gives an expansion to 
iliac fascia. 

The Iliacus Internus (Fig. 1 j;j, 8) nrin/x from the njipcr half 
of the iliac fossa, reaching the margins of the crest, iliac notch, »\«\ 
anterior inferior iliac 6i>ine ; from the sacro-iliac an<l ilio-luuilmr 
ligaments ; and, frequently, from the capsular ligament of the liijv 
joint. Its fleshy fibres nnite with the tendon of the pson.*, and nn- 
iwxrtcd with it into the lesser li-ochanler, and into the shaft for 
.ibout an inch below. A b\iTSH lies iK'neath the conjoined muscJi- 
between it and tlie capsule of the hip, and may couimunicnte with 
the joint cavity by a round aperture between the ilio-feni<>nil aad 
ilio-pubic bands. This is a channel by which pus may enter 
iliac fossa in hip disease. 

The psoas and the iliacus are flexors and external rotatore of 
thigh, and taking their fixed point below are flexors and rolal 
of the trunk upon the thigh. This is seen in dislocation of 
femur downwards into the thyn)id foramen, when the 
always bowed forwards owing to the tension of these muscles, 
psoas is supplied by the lumbar nerve.*, the iliacus by inlra-p«l' 
brunches of the anterior crural nerve. 

The Quadratus liumborum (Fig l.")3, 5) is the short m 
tilling the space between the last ril) and the crista ilii. It hi 
origin l)elow, from the posterior portion of the inner lip of 
cNSt of the ilium and from the adjacent ilio-luiubar ligament ; 
ascends to be inserted into the lower border of the last rib, and 
three or four slips into tbe l\\>» ot l\\e \.TOx\RvtTftc ^toce.sses of 



1 



liodyj 



TUE LUMUAU I'I.EXUS. 



32.^ 



Tunitiar' vertebne: It U soiuctinic^ <l(»H:ril>t;il lu con»i>ting uf two 

: parts. Thv c|uaJnitii8 dmwtt i|i>wn nnd flxea tlie la>t rib, 

..i.'i ' .tu'^iTK n •light lateral iiicliiiatioii of the trunk townnh the itiao 

crcal ; it U tupjilifd hy tliu poitteliMr lmiiiuhr« of the lunibor nKrve». 

Tinlfth ilortad vr Uioracie lurir (Kiy. 153, 3). — ClOMing the qujul- 

Via. Ii3. 




Tif. 163. 
X, Wglit nD4;liatt'4l ponl of tMiipu- 
Ihrtir. 

3. Ak>dumtn»l auiit. 
S, 3. Ijut lixnxi nerrm. 

4. P»CHi> pArrua. 
a. Quiulmua luiiiboruiu. 

• '• ■■•'iltBU*. 

Iiofutru ntrrcft. 

y, L'. lUv-iugiiin»l nwrvw, 
to. Luniljo^Mcial luTvii. 
)]. (i<inito-<runil tierv». 
Ulutrkl urTTv, |nrri'<', 

lltM£ hnarJx uf ilio-byyogiutrie 



Lumbw plextu (flnm Ilinchfeld rnirl LtveiUv)- 
H. Sunml i)!i'xu«. 

l/i, l<V !'>' Kitcninl culaiiouuani'rve*. 
IT. Tniiinrt'rsalU ntxlomini*. 
I!). I)lilii|uuii iiitiTiiut. 
21. 0blii|iiU9 t'xU'rniit. 
23, i'A. Ahloiiiir iruinl nfrvm. 
jA, i'>. Obturator riervra. 
'27, 27. t'nirnl briiDi'h of geoito-crural 

iicrvi'. 
2',). (Iciiiljil brnnrh of )^iiito>orunil 

nrrvt'. 
.'11. Exlvniiil iliac artery. 
'M. Eitomal abdominkirlng. 



326 



DEEP DISSECTION OK ABDOMEN. 



r tiu 




ratu3, and immediately below the ligainentuin arcualum fitCTimin, 
will be found u liirge nerve, the twelfth dorsal, which will lie 
to disappear through the traiisversalia muscle to reach the Imtti 
and must not be confounded with the branches of the lumbar pl«a 

The Iiumbar Plexus (Fig. 153). — Eraerjjing from tht? oalj 
border of the psoas, about midway lietween the last rib and tlie ci 
of the ilium, will be found two small nerves, the ilio-hijpvj(utnc 
and ilio-in;fuinal (9), crossing the quadratus obliquely anil jiirrci 
the abdominal musdea immediately above the crest, generally il 
together. They vary considerably in different subject^s one liein? 
often larger than the other, or the two may be re]>rfsented hy unr 
trunk which subdivides in the abdominal wall. The afttrr-coorse of 
the nerves Las l>een given in the disxection of the alxloniiiial wall 
(p. 257). The ilio-hy[xigastric is dii=tributed to the skin of tlie 
lower part of the abdomen, and by iU dorsal branch to the bii 
on the inner side of the last dorwil, and the ilio-inguinai eniei 
from the external abdominal ring to supply the scrotum and i. 
Hide of the thigh. 

The Genito-eriirnl nnve (11) appears on the front of llie pso^ 
its upper part, and is of small size. It descends on the niuscler, anJ 
divides into a genUid (29) branch, which accompanies the spermatic 
cord through the inguinal canal to the crema-ster, and a cnirtil (ly) 
branch, which runs under Poupart's ligament to the outer side of 
the external iliai; artery, and \» lost in the sl^in over Scaqm's 
triangle. 

The External Cuiantom n<riY (15) appears at the outer bonier uC 
the psoas just below the level of the crista ilii. It crosses the ili, 
obliquely to the anterior 8ui)erior spinous process, close to whid 
passes under Poupart's ligament to supply the outer side of the th: 
nearly as low as the knee. (This sometimes come.s from the ant«l 
crural nerve, and w then nearly transverse in its direction.) 

The AnUrior Crural (23) is a large nerve close to the out*r boi 
of the psoas at its lower part, and lies between that muscle and 
iliacus, giving branches to the latter and usually also to the fmi( 
artery. It passes under Poupart's ligament into the thigh. 

The Ohlitrator nrrtf (25) will be Vietter dissected with the jwl 
but may be seen passing below the brim of the true j>elvi3 iijion 
up])er fibres of the obturator intenius above the obturator vessels, 
disappear through the upper jiart of the thyroid foramen. 

A small .4c("<'Mor;/ Obturator nerve is occa.-*ionally found ari 
with the obturator nerve. It pisses over the body of the <» 
joining the obturaUjr nerve on the inner side of the thigh, uii 
supplying twigs to the pectineus ai\4 l\\e\iV\j y>mv. 



JlOfi 




SYMPATHKTIC NEUVE. 32/ 

[The pwHW xhonld Ix; carefully removed piecemeal on one Mv, in 
Older to dixsect the lumbar nerves to their origins, and to trace out 
the plexua completely. The gnngliutpd cord uf the sympathetic can 
now be fully seen, and Hhould l^e cleaned.] 

The Lumbar plerwi will now be seen to 1)6 formed by the 1st, 2nd, 
8rd, and part of the 4th lumbar nerves, with a branch from the l:2tli 
donal ; the remainder of the 4th joining with the .'>th to form 
the " lumbo-sacral cord." The several nervoux trunks are united 
more or less definitely by connecting branchoH, and from them the 
nerves are given off, thus : — from the loHt durwd and iHt lumbar 
the ilio-hypogostric and the ilio-inguinal nerves; from the Ist and 
Snd lumlnr the genito-crurul nerve ; from the 2nd and 3nl the 
external cutaneous nerve ; from the 2nd, 3rd, and 4th the anterior 
ctuial nen'e ; from the anterior iibrei> of the same trunks (Snd, 
3rd and 4th) the obturator nen'e. The origins may be tabulated 
M follows : — 

112 and I . . . Ili(v-hy)m;aulrir anil ilio-inguinal. 
12.. (h-nito-cniral. 
'2 3 . External <^<iluneoiiK. 
i 3 4 Anterior crurnl. 
2 3 4 Obturator. 

Sympathetic Nerve. — The (Smujlinted i'm-ih nf the S>imp<ithelic 
(Fig. 153, i) will lie found on each nidf of the sjiinal column, ami 
behind the vena cava upon the right sifle. A ganglion is HituaUnl 
opposite each vertebra, and gives otf a nunilH-r of brunches, which 
may be divided into (1) those communicating with thit ganglia 
above and below ; (2) those communicating with the spinal nerves, 
which are often two in uumlx-r, and accompany the lumbar arteries 
beneath the tendinous arches of the jimnis ; (3) branches to the 
plexuses upon the neighliouring arteries su])plying the viscera and 
the vertebne and ligaments. 

Some lymphntie glnndi (lumhnr) may al.'X) 1)e found surrounding 
the great vessels. They receive the lymjdiatics from the testis in 
the nude, from the ovary and Fallopian tube in the female, from 
the iliac and sacral glands, and from the a-scending or descending 
colon. A few renal lymphatic glands an- found alH)ve the renal 
veaaeK 

The Van* Asygoa Major may lie seen lying close to the right 
aide df the anrta, and communicating with two or more of the 
Imnbar veins, and sometimes with the vena cava or right n;nal. It 
poaaes thiongh the aortic opening. 

The Iioift IjOwbt Vena Anygoa may Im seen to coinmencb \n 



' ■ t *. V 



<1U 



328 



THE i^BDOUINAL VISCER-i. 



the left lunilmr veins or (mm thi- lelt ix-nal, iiiid to puan titoiigk 
(lie left cms ol' till! dinpliragtii. 

Receptaculiuu Chyli. — By ilutaohing the tight crus of ihr 
diaiiliragiii I'luni the verlebnu, and if nucessan', ivinoviny: a piece of 
the aorta opposite the upper lumbar vertebra;, the recejitarului.i 
chyli, the diluted oriyiii of this thoracic duct, will be seeu hiii„ 
between and behind the iiorta iiud vena cava, c^pjiosite the ^-ecoDil 
and third lumbar vertebitc. It receives all the lyiupbatics aiiil 
lacteals of the abdomen, and is continued upwards as the thonci 
duct 

The subject will now 1m: tm-ued for the dissection of llie b«ck, 
and the dissectors of the abdomen shouhl occupy the time with the 
examination of the viscera. 



H 



The STauoTUKE of thk Viscera ov thr Aboomex. 

[The stomach and inte^ino3 should be cleaned by allowing* 
stream of water to pass through them ; and the stomach, and portioi 
of the small and larj,'e intestine, shouhl be diatended with air by 
means of a blow-pipe, so as to ixnuit of dissection of ibeir coat*.] 



151) hoA been describe<l (p. 296) ta to 
niun1j«r — serous, muscular, areoUx, anil 



The Stomach (Fig. 
form and relations. 

Its coats are four in 
raucous. 

The DcruiU imtt hi continuous with the lesser omentum ab 
with the great ouientuui below, iuid with the gastro-splen 
omentum on the lell side ; the layer in front of the stomach 
derived from the greater oac, and that behind from the lesser i 
of the peritoneum. Along the lesser curvature the two layer* i 
peritoneum are separated by the gastric and pyloric vessels, 
along the greater curvatuitiby the gastro-cpiploic and splenic veaselikl 

The muncttlnr coiit consists ol' three sets of unstri|)ed fiVires, externa 
longitudinal, middle circular, and internal oblicjue. The longitudin 
fibres, running principally along the lesser cur%ature, are coiilinuou 
with those of the oyiophagus, and are continued into the duo 
denuni. The circular fibres, whiuh are uv\X in order, enclose tiitj 
entire viscus, and are tcdlected together at the small end to for 
the pylorus. The oblique fibivs, continuous with the circular fibres 
of the (esophagus, may be i^xpiwed by everting the viscus and di»-, 
secting awoy the mucous membrane ; they aitj distributed principal); 
over the great end of the stomach, and ore so ari-angeil around th 
cardiac orifice as to fonu a " button-hole " spljincler, one set 



THK STOMACH. 



329 



the ri(;ht iii<]o of the ttpvriiiig ^> afprciul out on either 

face tnwanld lli« left vitreiiiitv of the viscu*, tba other lu liki- 

r ciowltiK Uie l«fl Iwrder of the ojienuig to iwwh the more 

I lortiun ul' tlie grcalu uurve. 

Mi areoiar or tuihmuooiis tout coiisuta of arfolar tiiMue, in wbidi 



Fir I5«. 





nmifr the blood-veiseli an<i n rich lymphatic (ilcxtu, ami between 
tlii< anil the iiim^oiM coot in a tbin layer of involuntary tuiucle, the 
m%ueiilaru mueitmt. 

On laying; open the nlouiAch aloni? itu lenwer curvature, tlie 

' mfuihrrmf will lie wen to In" urruiif^eU ill longituJinnl foUli 

■ H culliil ruga, wliich di«iiii]i«tt.r when llie vihciw is (listeliiluil, 
,uiii ar« more evident in the child than in the adult. By id- 





n^. 154.— SeclioD or tliu atunia 


■\\ Mid diioiliTnuni (from WiUon). 


1. 


<E*;' 


11. D... ■ : ; tion. 


2. 


C*i' T th« "loniufJi. 


12. I'nii ' "Uil Juctm rolil. 


X 


Hr :,■• ftomiivli. 


II. DrliiiMcliiMlo their 


1* 


;<yl<<ri<: ulul. 


li'iiiiiuatiuii. 


P 


■ i-*.. 


VA. Piipilln iiixiii which the Jnct* 


■f. 




opi'n. 


7 


i!in priurui. 


14. Triiiiiivcnw (xirtinn of dundenuin. 


,h 


>jiD of thti inuvoun 


15. f'nnunt nri'iiiunt of jejimuin. In 
the interior of the diiodeiiiiin 




luriuUialii'. 


0. 


I'ylonn. 


mid jujiuiurc the valvulie oon- 


to. 


Aarvndiag portion of thr iliioilr- 
oum. 


nivpiit«« arc seen. 

1 




330 



THE ABDOMINAL VISCERA. 



verting the pyloric end the pyloric »phinc(er will \>e seen tut 
minent ring of strong; circular fibres, sun'ounding the inl 
beneuth the mucous membrane, and acting as a spliincter inti«cle. 

The mucous membrane is thick and soft, and of a pink coloi 
when recent ; it is thickest near the pylorus and thinnest al 
greater end, where perforation from post-mortem digtwtion ustull; 
takes place. The .surface of the membrane is divided into a series 
of shallow alvfoli, more or less hexagonal in form (stomach cells), 
the bottom of wliich open the tubes which secrete the gastric juii 
and mucus. ' Solitarj' glands ' or lymphoid follicles orr scan 
over the surface of the gastric mucous membrane. 

The Bmall Intestine is described on page 299. It may be 
regarded as a tortuous and greatly elongated conical cylinder, the 
smaller end of which o)>ens into the co'cum. It hat< four cotti. 
viz. peritoneal, muscular (longitudinal and circular), areolar, and 
mucous. The peritoneal coat completely sun-ounds the first part «( 
the duodenum, except at the attachment of the lesser omentum, 
where the vessels enter, while the second and third portion* are 
only covered on their anterior surfaces, and even this investment a 
incomplete where the second part of the tube is crossed by the 
attachment of tlio transverse mesocolon, and the thinl portion 
the superior mesenteric vessels. The peritoneal covering of 
jejunum and ileum is wanting only at the point of attachment 
the mesentery, where the nmscularis of about a fifth or a sixth 
the gut forms the base of the interserous triangle (Fig. 144). 
muscular coat consists of an external layer of longitudinal ftbrvs 
an internal thicker layer of circuLir fibres, both comjdete and r^on- 
tinuous. The mucous membrane is amplified in extent of *urf»r^- 
by jilications called valvulic conniventejj, by papillary projection* 
calleil villi, and by follicular involutions known as tulies of Lieb«r- 
ktllin ; and its tliickness diminishes progressively, together with the 
calibre of the gut, as it becomes more remote from the stomach 
and approaches the coecum. Racemose glands (Brunner's) are found 
in the upper part of the duodenum, and aggregations of lymphoid 
follick'3 chiefly in the ileum, while solitary lymphoid follicles are 
scattered throughout the intestine. A vimciilurU murnut is |i 
in the submucous tissue, as in the stomach, and enters in' 
fonnatioii of both the villi and valvulae conniventes. 

The vah'ulw conniventes (or valves of Kerkring) are tninsvetie 
folds of mucous membnme and submucous tissue, which will I"" 
seen to commence about the middle of the second stwge of the 
duodenum, and to increase in size as they approach the middle of 
the jejunum ; below this poiul l\icy Vi«to\\\c suuvUer, di.iappearing 




iJtai 



UllUUIC »« I 

[tearing >^^ 




THE SHALL IN'TESn-INi:. Sol 

the lower fourth of the ileum. Ther extend art'itml aKiiit t««^ 
thiida of the cinrumfeKnce of the (.nit. 

The I'Uli an niinnte pryev-ti'-n* from the furfaoe of the miicon* 
membrane, and give it a vrlvrty ap]«'anince. whi>-h may ]« K'st 
wen hj floating a piece of intestine in water. Thev U-jriii at the 
pyloric sphincter anii en>i at tLe ilei^coxal v.tlvr. mu\ attain their 
greatest length (about -jV.th of an in(h)'«ht-re the val\ul:e conni- 
ventes an mo^t developni. Eaeh villus i< a pn'l<>ii)>ition of the 
mnoous membrane, furmeti of lymphoid tissue an^l i-ovenil with 
oolnmnar epithelium. It ci'>ntain$ in it# ci-ntre a siii^^le »r double 
llftoal, surrounded br a delicate layer of inv<'lunt.iry niiisi-le pn»- 
longed from the muteularui inufo^ : externally to which is a 
eapillarr pleso(>, with the l«»emeut -membrane i>n which the epi- 
tbeliom rest*. 

LitberiMhu't /ollirUt ai« minute tuU-s Iine<l with columnar 
epithelium, and common to the whole of th<- small inteMines. 
iniey are placed between the villi, and iliji into the stibmucou* 
areolar tissue, their depth being pro|H>rti><nate to the thi<kues.4of 
the membrane. 

The Solitani /bllicle-t are *een a< white n>und l>o<lie< aKtut the 
size of millet seed, containing a milky fluid. They cou.-'ist of 
lymphoid timue, and are found in the whole length of the digestive 
tract, but are most numeroii« wheiv the niuhiplicaliuii ot ^urface is 
leaat 

Bnintut'$ gland*, peculLtr to the up]K-r ]>:irt of the diUHlenum, 
are small racemose glands situated in the submucous areolar tisi>ue 
and opening into the intestine by minute duits. To see these it is 
necessaiy to pin out a piece of duodenum with the imicous mem- 
Inane downwards, and then carefully to dis.-iect uway the iiius^-ular 
coat. 

The Snodannm (Fig. 154) should Ih- laid o]ien along its free 
bolder, in order to see the common (ijK-ning of the bile and ]mncr«>- 
atie dacts, which is marked by n ]ia]nlla situated at the Imck of the 
•eeond portion of the intestine, and uliout or lielow its miildle {l^) 
A second opening, the atcfttury ilurt of ifmilnriiii, conn<-<'ted with 
the lesser pancreas, may sometimes Iw foun<l above tlii<. ]Ktrt. A 
probe should be pas8e<I through the ]>apilla into the coniniou bile 
duct and along the pancreatic duct. The duixlenunt is the widest 
and thickest portion of the small intestine, and is charaeteTis<-«l 
•tructurally by the presence of Umnner's ghinds in the mucous 
membrane of its upper segment. It contains also valvuhe conni- 
ventes, villi, Lieberktthnian tubes, and solitary follicles. 
[Tbejy'anani and ileum (except a fev inches to be \etl aUncVevX 



332 



THE ABDOMIJTAL VISCKRA. 




RtO, 



to the ca'CUni) sIiouUl he luid open iiUm^^ ti-.e line of attuhnUDt 
till! iiicHHUterv, in onler to avoid damaging Pcycr's patcha^ 
urc at. tile o|ii>u8ite side of the j^iit.] 

Tlie Jejunum, including about two-tiftlis of tbe reiuaining isudl 
intcritine, is remarkable for tlie h\ty,ii size of the vnlviila; conniventw, 
the {,Teat development of the villi, and the niiiuber of «olil 
full idea, but has no special charaeteristic. Its iioiuinal aepantii 
from the ileum is arbitrary and useless. 

Ill the neum the valvuhu i-unniventes will be found to diminiill 
lapidly in size, and to be absent altogether at the lower part A 
snuill tube or curd may sonietinaes be found in connection with the 
gut, about thit'e feet from the ileo-coccal valve, extending towards the 
umbilicus. This is called Merkfl'ii lUcerliculuiii, and is « relic of 
the vitelline duct of the f<etus. It is occasionally the cause of 
internal strangulations, and of lunbilical fa-cal fistula in newly bo: 
children. 

J'fijer't pntdia (gUindHlat aiimiiiatiK) are the special charaeterisi 
of this port of the intestine, but are ocausionally found in the jej 
nuiu ; llu'y nn- from twenty to thirty in numlier, but vary much 
size and are riomelimes invisible. They will Iw recognised ai 
fhallow oval or rounded depressions, dotted on their surface, and 
a lighter cohjiir than the rest of the intestint% and am always fou 
on the part of the int(!stine farthest from the attachment of tl 
mesentery. Each patch consists of a collection of lymphoid follicl 
Peyer's glands will be iouiid iullaiiied, and souietimea ulcerated, 
subjects which have died nl' typhoid fever. ^ < 

The Large Intestine is remarkable in nearly the whole of 
length for a poucheil appeamncc, conseiiueiit upon the longitudi: 
muscular fibivs being shorter than the intestine itself. Typi 
these longitudinal fibres are ariiinged in three rlistinct bonds 
t<tHi<i:, two of which can !» seen through the peritoneum, and the 
third between the layers of the meso-colon ; but in the rectui 
which is not pouched, and the vermiform appendix, the fib; 
spread over the whole gut, as iti the small intestine. The ayptndi* 
Kpiploirir are small jirocesses containing fat, attached along the fi 
Iwriler of the int«stiue, and will be found to vary considerably 
size in dilferent subjects. 

[The cujcuiii with a few inches of small and large intestine «hoi 
be detaclied, and the large intestine turned inside out to see the ili 
coecal valve. After this has been done and the intestine re-inverti 
the cut ends may be tied and the jiiece inflated ami dried, that I 
valve may be again examined.] 



01 

i 



THK PANCBBA8. 



:}33 



L.The tl»<tfeal noiiv fFijr. \^>'', 5) i» formed liy 11 prolongfttion nf 

^h mucous meniLraiir anU i-iix-ulur tibre* of ilir niiixcular ocwt of 

^Rnni into Uie cavity of tin* ra-rurn, and Hp|:>vur» on twu fiililH 

boutxiiti); a burixonul f^lit-likc npcrtim; of cuiiiiiiuiiicMtioii. The 

upper fold or flap, which in hori/ontnl in dirtclion, is aoniftinic* 

, known ns the i7««-co/iV, and ihf hiwi-r or luon- vrrliiiil om- u» tU>: 

traJ fold. Two ridni'«, oiir mi t-iiili oiiir, fxti-nd from lb«^ 

of union of thi" two fold^ ond un- I'nllcd the fraiia or 

«/<!. Th'-' \n\\y |>vruiit« thf rcudy poimage of fluid from the 

tile luiyfv iiiti'«tiue. but oppo»e)! rt-KUi^itation. 

Y\f I'Vi. 




e macoiiti Tnenibrnni- of th^ large intoAtinv hoH vn villi, thvM' 

ig uliruptly at ihi' fifo margin of tlic iU'tvi^irrdl valvv, but 

blex thutof thr hiuhII intcxtint.' in hitviii}; riiluinnar fpitlirliuni, 

lur filnndf iviu-tublin;; llii- f>i||icleM of Lielx-rkUhu, mid Military 

icle«>, rnilieddrd in thf fiibmui-ous tiaaue. 



> 166. — Tbr corcum laid opm, >ho«-!m; thv trrminiiUon of the Utum and tli« 

ilco-c'ircal mill' (fiani WiImjii). 

(colaii. 0. Lower fnlil (if ilpo-oa'cnl val»r 

rorptiiii; tlir upper fold to roriii 
a rvtifiui-utuui. 

fv III. 7. Fold of eolon. 

,\ -ro-nsl ru/ic. 




334 



THE ABDOMINAL VISCERA. 



The Pancreas (Fig. 145, owl p. 301), sLoiilJ be cleaiiwl, littt 
left uttacbe<] tu the (lucHleiiuiii. It ia a comi)uuiid nicetnoee gl<nd, 
luid consists of lobules of a yellowi«h colour held together br \nom 
tibniuB tissue, a small duct jHUisiu;{ from eAch lobule iiitu the tmin 
trunk. A prolte should be [iiissed from the duodenum ititu iht 
duct (canal of Wirsung), and when dissected out, will be foiusl 
to pass along the whole length of the gland, nearer the poitcrior 
than the aDt«rior surface. A large accessory duct passes from tbt 
upjicr |iart of the head and occasionally opens separately into ih* 
dutKlenum. 

Tlie piincroatic duct lies close to the bile duct, and the two pierw 
the duodeiiid wall, upcning usually by a common orifice upon 
fiummil of a small papilla. 

Fig. 166. 




The Spleen (Fig. I4b,ipl) has been alteafly figured and describ 
(p. 307), and may now be removed and examincil in sectia 
Beneath the peritoneal cout which invests the or^an, will Ije foil 
a fibrous coat containin;; an abundance of unstrip«<l nmscull 
tissue, which is continued into the splenic substance, to farm 



Pip. 166.— Upper suifiuie of the liver (from Wilton). 



1. Ri^ht lobe. 

2. I^ftlobe. 

3. Fundus of tlic (nill-hlndder sren 

projnrtin^ boyond tl»c anterior 
oordiT of the riffht lulif . 

4. Pofltcrior or roiinde<I border. 

6, Falciform or siispcnMiry lignment. 
6. Kound ligament. 



7. 7- The two lateml li^ment*. 

8. The uparc left unoovwrrd br I 

peritoneum and surrounded b; 
the roronnry liiinuuent. 

9. Inferior vena cava. 

10. Point of the lobu» Spi^elii. 
• • Position and direction of Bjoitl 
sagittal plane. 



THE LIVER. 



335 



or mishes in which tlie e]ilenic piJp is contained. In 
this pulp, which tonsista of ii retic.ulutii of bninc]ied coimective- 

Ke corpuscles (Quain), are fouml the Malpiyhiaii corjnuteks, small 
il or ovul iKKlies utlacbeil to the minute divisions of the splenic 
litCTT. They are couii)osetl of lyinjjhoid tissue ilerived from a 
.taufonnatioii of the externnl or areolar coat of the small arteries, 
lavernj^e »'„ inch in di.inieter. The artent-s end in capillaries', 
lose theuiwlves in the connective titwiie of the pulp, in the 
tice.s of which the hlood {lows. The veins anastomose freely 
Dd u|«in the traheoulw, and ojwn into the .nplenic vein. 
Le Liver (Figs. 156, \Ty7) when removed from the hody loses 
h very lar^c extent the form which is impressed upon it by the 
kX of the alxlominal walls and the netuhbonriiig viiiccnu 
IpteKnts upper and under surface.-, united by a thick posterior 
and a thin anterior margin. Its ordinary measurements 
twelve inches across, six fmm before backwanls, and three 
I in its greatest thickness : and its weight is from three to four 
nds. It is fixed to the diai>hrugui by j>eritoneal reflections, 
bich are called resi>ectively the snjjerior or falciform, the poeterior 
keoniaary. an<l the right and left lateral li^-amenti, and by a fibrous 
resulting from the obliteration of the umbilical vein of the 
tf, which runs to its lower surface and is knoivn as the 'round 
ueuL' The upper surface is divided into two iinenual parts, of 
well the right is the larger, by the attachment of the falciform 
Dent, the two layers of which will l>e foinid to diverge 
*riorly, forming the upjMir layer of the i-uronanj an<l the lateral 
If the /«/) Intend liffamfiit be tracecS, it will be found to 
(of a double fold of the peritoneum, which iimy be followed to 
I left border of the left lobe. The upper layer of the coronary 
Dent, if traced in the isame way to the right, will be found to be 
xled upon it.«elf In form the riijht lateral liijnmeiti, which is much 
«r thim the left, and then will be followed to the under surface 
■ Ibe right lobe of the liver, to form the inider layer of the 
nary ligament. A morc or lesH triangular interval is thus left 
»een the two layers of the coronary ligament, where the liver is 
nbed to the diaphragm by cellular tissue and is in relation \vith 
* right suprarenal capsule. 

The upper surface of the liver is dome-«hape<l, and moulded to 
ibe iauer surface of the diaphragm and to a small jiortion of tlie 
•ittriiir abdominal wall at the suUcoetal angle, and may be regarded 
" Uring superior anterior ami right lateral fates, ll '\s 8\\^\Vj 
''•pwMed at its summit, where it is sejwrated by the du\Y)\iTagttt liom 
J^fkeut (impresaio cardica). 







830 



THE ABDOMIKAL VISCERA. 



The under Bur&oe (Fig. 157) jiresents three Jumntt nnd 
lobes for examination. 

Fi*furet. — The Umgil uihnii) fitaarr iliviiles tlie unrler mrfnrc ta 
right and left lobes, and is iliivctiiil iilili<|Mi>ly fiom ii jMijnt twf>( 
three inches to the right of the 8(if;iltal plane in finut, to i-nil »Ik) 
an inch to the left of the pbinc liehiml. It is occupied aiiteriuriT 1 
the obliterated umbilical ^•^-in, and behind the traii«ver«e tiBsute 1 
the cord-like relic of the diictus ventMus, wliich lies between 
two layers of the upper attached border of the wptal foUl 



X s 4 .'. u 



Fi*:. 167. 

T » 



10 




n 913d l» IK 17 



Fijr. 157. — Under Kurface of 



1. Cut edgo of left lnf<TBl liir»ni<'nt. 11. 
'i, Tuber omentale of Irft lube. 

3. (Ewtihageal notch. 12. 

4. Surince of lircr uncorered by Vi. 

pcritonpiim. 14. 
0. Fipsuro of ductus vprio*u*i. 

fi. Spigelian lobe n-ilh cut edge of IS. 

peritoneum of leSMT use. IC. 

7. Vena cavn. 17. 

8. ImprcMion for (upra-rcnal cnii- IS. 

•ule. 1!). 

g. Portion of li»er tiplwwn Inyers nf 20. 

cortmar) ligiiment. i!I. 

10. Cut turfa'ce of upper layer of 22. 

coronary ligament. 



the liver (W. A.). 

Cut edge of right lateral 

nu-iit. 
Rcniil imprcaiuon. 
Colic imprcMion. 
Cut I'llgo tif I'uronary lignmnil^ 

inferior layer. 
Duodenal impression. 
Unll bladder. 
Lobu-s eaudatuR. 
Common bile duet. 
Portal vein. 
Hepatic arterj. 
Round ligament. 
Oustrii: inipre««ion on 



THE LIVER. 



337 



aeuni, continuous with the left extremity of the lesser omentum 
(tw p. 284;. In the fietus »t term Ilie lotygitudinul fissure is 
towly medial iind wi^rittjil, hut as growth proceeds its anterior 
aitemity f.hiftH gi-iiiiuully Uiwanls the right. The tniiwversg or 
frntnt Jiuuiy which is iilso obliijuely directed lies at right angles to 
tlu' lungitudinal ; the .ittiall oiiientiini is attached to its borders, 
uil it j^ives poBsage tu the hepatic duct, he))atic artery, ]iortul vein, 
lymphatics, and nerves, and to a connective tissue sheiitli for these 
Kricturc" derived from the ciipsule of Glissoa Parallel to the 
liiugiludinal fiMUre hut more to the right is the fossa ov fitnurt for 
At i/tUl-hlaiiila; a shallow dejireMion usually uncovered by peritoneum 
•ad in ilirect contact with the opposed wall of the gall-bl adder. 

Lo4m. — The whole of the liver substance on the right of the 
lom^'itiidinal fi*<ure is strictly the ri'jlit lohr (Fig. 137), but certain 
P«rt.» bf it have received B|)ecial names, viz., the lobus quadratus, 
til' lobus Spigelii and the lobus cj\ndatus : the surface to the right 
uf lliesi: being calletl the 'right lobe proper.' The riglit lobe has 
tlute shallow depressions on its umler surface, oiie anterior, where 
llif ascending colon touches the liver (19), one posterior, cnrrespond- 
i!i|; to tlie anterior surface of the right kidney (2 1 ), over which it 
li" in the erect posture, and between and to the left of these iie«r 
tilt neck of tJie gall-bladder a small impression for the hepatic 
fifiiire of the iluodenum (15). 

The Jjjbiu i/iiadratiu is a square lobe bounded by the longitudinal 
"kI tnmsven«e fissure*, the g<ill-blndder, and the anterior border 
"1 tbf liver, and is often connected with the right lobe projjer 
W u bridge of hepatic substiuji^e [jkihk hrjjutU) across the round 
li-nincut ; it is in ndation with the jiyloric end of the stomach 
Mil ilji. first part of the duodr-nuni (1). The Liibm Sjiiijelii (12) 
•it' Whind the transverse fissure, and between the fissures for 
tilt Vena cava and the ductus venosus. It will be described 
*Hb the posterior surface. The Ltibm ot uiliitiai (ii) is a small 
'l4ir of liver substance which connects the lobus Sjiigelii with 
'w rij;ht lobe proper, and lies behind the transverse fissure, 
h ("nu» the ujiper boundary of the foramen nf Winslow and is 
"tiwl by the j>eritoneum connecting the greater with the lesser 
•'• The left lubf is on the opj)osite side of the longitudinal fissure. 
" pfwi'nts a rounded ]>rominence corresponding to the lesser omen- 
^"K the tuber omentnU (4), and around this, nearer the niurginal 
"»ler, u concavity, the ijiutric impression { i ) whiidi is continuous 
*itli ihf gastric area upon the umler sni-face of the ln\)ua i^uaiTaVua, 
•■"l witli a rounJed a^soji/iuf/eal iioMi [6), on tbe poatetioi \Kiti.a 
^ tit abdouiiaal portioa ot the u-aopliaifus. 






338 



THK ABDOMIKAL VISCEKA. 



The vessels enteinng the traimversv ficsure shoiild l>e ilcfineil, i 
the fibrous tissue around them (ca)wule of GIJHiimi) reniovetl. ' 
right and left hepatic duel* will I* found to euiergL- froto 
corresponding lobes und to unite in the (ommon hepatic rfiirf, whicl 
is about two inpiieji long ; tliis is uflerwurdK joinetl by the tifi' 
duct from the 2<]l-bladdcr, and forms thr common hilt <l>trt (dncti 
couiniunis cbo]edochu!<), a tube nearly three inches long, vhiei 
should be tracdd into the duodenum. 

The posteriorftOTfaoe consists of ( 1 ) a small portion of tlie I 

Tig. 168. 




lobe, togellier with its ufujiliayiul uutch near the termination of ( 
longitudinal fissure ; {-2) the greater part of the jimuTe f(n- Iht diieii 
renosus ; (3) nearly the whole of the lobus >5pigelii ; (4) the^ 
for the vena caitt, with, perha|», a panticulus or little bridge 
hepatic Bu)jstance crossing the lissure behind the vessel ; (6) 
portion of Uie riyht lohe proper which lies between the layers of 
coronary' ligament and in direct contact with the dia]ihnigin. 
is here that an important anastomosis occura between the phiei 
and hepatic vessels. The Lobtit Spigelii * is an oblong loK 



Fig. 158. — Kabbit's liver iuJMte<l, showiup a i>ortal vein, with intorlobultf 
brauc'het nnd plpiiu. IntmlobuUr ruin comiuoncing iu tlie centra of > 
lobule (from Frey). 

* In u liror rcnioi cd from the body the lobuo Spigelii appear* to form s p«rt of 
b« uiiijer surface of the orgun uid the &ot^i£ uivvTwai&on u\v(Hi.vts «arface r '~* 




THE LIVER. 



339 



booaded below and in front by the traiisverMe iiMiure, on the left by 
the fiMUTe for the ductus venosus, und on the ri^lit by the fiwuns 
for the Tena cava ; and i* connected inFeriurly with the right lolie 
proper by the hbm eaHdatut. Only itx lower iMinlvr iM-longs tu the 
inferior surface ; the reitt, looking directly lMiukwanI.«, preiMintii a 
Tertical aortic impressiun, and iii Heimmted fruni the ImmUcr of the 
10th and 11th dorsal vertebra by the diaphragm and the thoracic 
aortiL It ia the only ]>art of the liver that in cuvi-rud by the 
peritoneum of the lesser sac 

The fiuurr/or the vena cava is almost vertical, but inelineR Hlightly 

Tig. \.V>. 




inwards as it descends. In the livi-r, aftiT mniovnl from tbi- Wly, 
it often appears to be very oblicjuely dirvctv<l ami almimt liorizontul. 

The entire organ is invested by a coniK-rtivc ti.i.^ui! coat, the 
«af$uU of Glition, which iii infli-cti-d at ttict tnuiitvemt- fissure and 
fidloWB the portal canals. Thi- capsule is must apiMin-iit where the 
peritoneum is deficient. 

The gall-hladder {t ^) is a pear-i<Iia]icd bag attuclied 1>y cellular 
tiasne to the under surface of the liver, and covered sniK-rficially by 
the peritonenm. When <listcndc<l, its lar^'e end or fmidits projects 
b^jond the anterior border of the liver, and approaches the juirietes 
Qpponte the point at which the linea semilunaris joins the right 



Figi IW. — Oiagtim of ths circulation in the lubulrs of the liver (after 
Kiemon). 

4 4 Jmlnbbultr nau. 6, i. Interlobular veins. 

■t. 2 



340 



THE ABDOMINAL VISCERA. 



costal lx)rder ; tbe neck is curved upon itself twice ami ends in 
cyatic duct, which is about lui inch and it half long iind jotiu 
hcpntic duct. A fuld of i)critoneuiii continuous with tbe rig 
extremity of tlie lesser omentum is often attached to its imil 
surface. The mucous membrane in the fundus presents nunieta 
alveoli of irregular shape with iutcrvoninj; ridges, and in the neck ( 
somewhat spiral fold. The epithelium is* ailunmar. 

Thehej'atic artery and the portal vein each divides into right tod 
left branches, and the cystic ))rauch should be traced to tbe gtU- 
bladder from the right artery. 

The piece of the vena cava removed with the liver is to be U 
open, when the large heimtic veins, from the right, left 
Spigelian lobe.«, will be seen opening into it, and its coats will 
found almost devoid of muscular tissue. 

In onler to learn the urrangement of the vessels in the liver, 
vena portie should be carefully oj>ened for some distance with » (4 
of 8cis.sors. Through the thin wall of the vein a branch of inje 
hepatic artery will then be seen, and accompanying it is a bti 
of the hepatic duct, the three vessels thus lying side by sU 
a cjmal {portal canal), bounded by an inflection of Glisson's capsu 
and containing, besides the vessels named, branches of lymphntil 
nei-ves, and some connective tissue. The portal canal thuu enclo 
rc[)re6cntativej* of all the structures entering at the portal ti»«U 
One of the heiiatic veins being laid open in a similar way, wxll 1 
seen to run alone in close contact with the hepatic lobules. 

An incision intf) any jiart of the liver will show on itc 
surfaces a numlier of openings, some usually gaping, — the hep 
veins ; othera more or less collapsed, and having by their sides 
sections of a small injected artery and duct. These last ar« 
portal veins, which tend to cullajise on account of the loose utb 
ment of the fibrous tissue arounil them in the portal canals. 

The blood from the cliylopoietic viscera is brought to tbe liverl 
tbe vena portie, and from it the bile is 8ecrcte<l. The divisifi 
the vein have been seen to pass through the })ortal canals, in whS 
they receive rnijinal and aipxalar brauchea from the fibnvus tissuoj 
the organ, and subseipiently divide until their branches run l/ttu 
the minute lobules or acini, whence they are called inUrlolmlur ■v<rNi(l 
From these interlobular \eins is derived the luhulur enjiilUiTy pUa 
which converges towards the centre of each lobule ajid poU 
its blood into the intralobular rtin (a). Each intnilobular vein 
passes out of the lobule at right angles to the portal vessels, i 
unites with other intralobular veins to form the lublobular veia 
bese open into the liepatk reins, v;\i\c\\ \u\Ne Wcvi Vcatei. vivVa 




THE KIDNEYS. .'HI 

▼ena cava. The appeannce of a piece of minutely injected liver 
ia shown in Figs. 158, 169. 

Each primary hepatic duct originates from n plexus of inter- 
cellalar paaaagei or bilinrjr capillarieB, which run towanls the 
cizcumference of the lobule, and unite with nuliclen of adjacent 
lobule* ; the resulting ducto running along the ])ort»I iMinulH by the 
aide of the portal vein to emerge eventually ut the trauHvente tixsure. 

The Hfpatie artery in destined princiiially for the nourifthnient of 
the tlMue of the organ, and ha« little if anything to do with its 
■eereting function. It gives off vaginal brunches wliit-h run in the 
portal canak, and eapndar branches which sujiply the fibriiuH ti>«ue 
on the surface, the blootl eventually returaing intii brancheH of the 
portal vein. The terminal interlohnUir branches uccomimny the 
interlobular veins, and their blood enters the interlobular plexus 
from which the bile is secreted. 

The Kidneys (descrilied on ]iiige 320) may now Iks removed. 
Their relations to the posterior alxlomiiuil wall shuuld Iw noted, and 
the structures within the siuiu diiwevtetl. 

The ureter, if traced upwards, will Iks found to ex]>and 1>ef<)n; 
leaching the hilnm, forming the pehi» of the kitlney, and it should 
he noticed that the pelvis has a direction downwunls ; no that by 
referring to this, to the {Misition of the vcsRel!<, and t<> tli<- tlattening 
of the posterior surface, the siile to which the kidney Indmigs can 
T)e readily ascertained. The organ is enclosed in a tough til>Mus 
capaule, which may be ]iccled otf fn)m tlit* r<-nal tissue. To sec 
the internal structure, the kidney olioidd be ii]iened tlinmgh the 
convex border by a vertical incision, wliirli is to 1h; curiied into tliw 
pelvis. 

The PeleU (Fig. 160, P) will usually l)C found to be sulnlivided 
into two tubular portions, the myrior an<l infi-rinr jH-lren, each of 
which may branch into snuiller tulies, called Iiifundihuhi, In'fore 
breaking up into their terminal branches or ('iilirfs. Tlie r.aliccs 
are fixed to the bottom of the sinus mitilit, ai-ouml little mslules of 
kidney substance termed the jm/nlla: or mnmillm (c), which are the 
■incea of the pyramids nf Miilpii/hi (>»). TheM> pyramids are 
eonicnl in form (triangular in the sedion), and darker in colour 
than the rest of the tissue, and are arranged more or less regularly 
aide by side. They constitute what is <-alle<l the tuhulnr or vtedul- 
laiy sabstanee of the kidney ; the lighter granular iH>rtioii or roHex 
lies at the margin of the section, fonuing a layer over the bases 
of the pyiamids and sending processes called ('vliimn* of Jlertini (i) 
between them. 

The zenal arteiy breaks up into four or five branches, vr^nt^^i 



342 



THE ABDOMINAL \nSCEIU. 



agahi subdivide and ]ul9s into the coluiuuse lieitini l>etwc<ii 
pyraniids to the cortical substance, funning cDriiro-meduUary 
between the cort«x and bases of the MnlpigUian pyramids. Frni8 
the»e arise the inUrhhular arteines, which ))a33 bt'tween seyuient-i of 
the cortical substance calle<l ptframicU nf Ffrrtin (Fig. 160, c I 

Fig. 160. 



u ' 



■^ 



^"— (jf«r 







%l|il i-", 



'3^ 111. :i-i 




and give oil' affcrtul arteries to tlie Malpighian bodia or giomendi 
(Fig. l<i\,g). Each Malpighian body h enclosed in a capeuU ai tb 
exti"emity of a minute urinifeToiu tithe (i), and consists of a capil 
plexus with an arterial twig (or afferent vessel) entering, and 
venous radicle (or eflcrent vessel) leaving it, and these bodies 
arranged along the arteric-s like bunches of currant.^ \ipoM a sti 
The uriniferoiijs lube (3) connected with the cajisiile is convoluted n 



Fig. 160.— Section of kidney (after Henle). 



11. t. Uriuifcroui) lubes. 
c. I. Cortex with pyramids of For- 
reiii. 
m. Pyramidt of Malpighi. 
i. Column of Bertini. 
p. riipilla. 



r. Calyx embraciug papiUi. 
m r. Medullar^' ravf. 

r. Pelvis. 

«. Ureter. 
</, a. Artery. 



THK KIDNET. 



849 



curtical •tibttaacc, and u nvcouiliit-y interi uhainr plrxiu i» formed 
ami it by the venoun nulicU- which enicrguj from the Maljiighian 



Fif. 161. 




:y\ 



^ 



ar 



Liri 



om 





>A 



Fi«. 



161. — Sclieoid of tliF mt«l liitwn a ml 1>l<HMl-vt»«al* (ftom WUaon : 
moUificd from Klein). 

On the left of \iw tl);uri> tho arninKmnviit <if the bliMxl-Teoel* of the kidacy i* 
on the rifht thr coiirwi of the urinifemiit lulmie*. 



r. i. 
f. r. 



», r. 
I* 



Tnm 

Frr 

\ 

V.-;:. 

V.-Wr 

In' 

(. 

A: 

_>■<• 



•tcllul.r ..r Vr.li. veil. 



KxlulUr}' part. 



«f 



I. Mnlpighian eapiule. 
•2. Nerk. 

3. Fint ronrnluted tubuls. 

4. Kpiral tubule of Schacbowi. 
fi. liewiendiiiK linib of loopat tabula 

of UcdIp. 

<S. Ikiid. 

Ti K, U. .iiiccndiiig limb. 
lU. Irrctruliir tubule. 
II. Sei'iiud convoluted tubule. 
I'i. Janc'tionnl tuliule. 
i:i, 11. L'ollc'cUni; tubule. 
I.j. Eioretory tubule. 



344 



THE PELVIS. 



tul't. The tube then becomes swldenly tmaller, and paMM for I 
variable distance into the pj'raniiJ an the looprd tube of HenU (5 — q)i 
again curving upon it-telf it reaches llie cortex, increases in me, 1 
opens into the eoUrctiiiij tiibvlft whicli represent tlie axial elcmen 
of the pyramids of Ferrein (13, 14). The uriniferoiis tii)>cs of tin 
pyramids of Malpighi, formed by the colIectin>{ tnbuleH, ronver^ 
at their apices, and unite to form a smaller number of InTj^-er tiilw 
which finally empty themselves into tlie ralicea ; from lhe« the 
urine passes into the infundibida, and theuce into the pelviii lut 
ureter. Between the straight tubes of the medulla are liumcrnu' 
recurrent arterial branches [a. t.) from the cortico-meJullary arches, 
and these are reinforced by straight efferent vessels from siime of 
the deeper glomeruli. The renal arterj' also supplies the fibroa 
capsule of the kidney with branches, which anastomose with th 
lumbar and plirenic arteries. 

Tlie iitlerlohuhn e<im, after receiving the blood from 
secondary plexus on the tubes, accompany the interlobular urteiii 
and unite in arches at the base of the pyr.uiiids. between y> hieli thf 
pass as the utraifiht veins, to emerge at the liilum and form iho ren 
or mndgent vein. On the surface of thi- kidney may be seen Mu 
venous radicles forming, from their arrangcmeul, what are knuM 
OS the Stars of Verheyen (r. x.). They receive bloo<l from the cupsu 
of the kidney, and jia-i.* inwanls to join the venous archesL 

The Supra-Senal Body is enclosed in a fibrous car>pule, and 
on section will be seen to consist of two parte, corticJil «n<i 
medullarj', the former yellowish in colour, the latter d«rk brown 
and generally broken down in the centre by decomposition so uk fi 
form a cavity. 

It is abundantly supplied nith arterial blood from the aorta anil 
from the phrenic, renal, and hmibar arteries ; and it* iiervw ai» 
derived from the solar plexus. The form and relations have lirm 
described on p. 322. J 

Thk Pelvis. * 

The subject being replaced on its liack, the dissectors hIiouIi 
proceed with the examination of the pelvis, unless they we 
unable to finish the aorta, lumbar plexus, imd iliac arteries befiX 
the body was turned, in which case they must revert to tb 
dissection of them at once (v. p. 311). In any case the dlsju-cta 
are strongly advised to read through the dissection tif the Ac 
parts of the nlxionien again, before proceeding any further. 

They should, moreover, olisen-e that the pelvic cavity bends 
twarda at an angle ot about, \\0° vjlvVi vVval of tho aMonwn; 



A 




THE PKLVIS. o4;') 

that the plane of its inlet lookH forwanli) rather than upwards, 
forming an angle of 150° to 155' with a vurticjil line xtrikiu}; thr 
promontoiy of the KOcruni ; and that the Byniphyni.t ami sacrum are 
more nearly horizontal than vertical. Fidiu thin Ktn>ii;{ inclinntiuu 
of the pelvis it follows tliat moKt uf the vi.sccrii in itt cavity lie 
above a horizontal plane at the level of the ti)]i of the HvuiiihyKis, 
and are hence moni or lew accesxible to i>ul]iiition ihitiugh the uIhId- 
minol walL 

[The pelvis with two luniltar vertehi-ic U to 1h- st-iiurali'cl from the 
trunk with the saw, when, by pliicin); it on si table with tlie Hiicrum 
towardn himself, the dis-sector will Im- ulilc to jfrt a lietter view of the 
contents than has yel been }Ni!ijibl<-. The cavity of the ]>elvis shuuld 
be carefully sponged out, ami the dissector siioiiM let u Htreuiu of 
water run throu<{U the rectum, alter which the blaiider should be 
emptied of anv urine it may contain by pressure with the hand, and 
should be moderately distended with air.J 

The Peritoneum (Fig. 104) should 1m- e.\aniiiiecl first, uud will 
be found in the Male to ihiss over the ivctuiii, biiidiii;; the upper 
part bj the front of the sacrum (nieto-rrrtiini); from the ii-ctuni to the 
bladder, fonning the rrcto-rrtirnl pmirh : and thence over the luick 
of the bladder to the abilominul wall. On each side of the recto- 
vesical pouch it overlies the obliteruteil hypi>}{xstri<' arteries and the 
lUeteiB, and the folds so formed uiv called the jmitUriur fidm- liiju- 
mmt* of the bladder. Passing; from the side of the bladder to tin- 
pelvis it forms the luUnil fnlnf liiiumnilH : and tin- iii>rtion rcachin;: 
to the back of the alxlomiimi wall over the urachiis is known as the 
tuptrior fahe lujament of the bhulder. Thus the false ligaments of 
the bladder, five in number, are all formeil by iH:ritoiieuiii. 

In the Female (Fig. 133) tlu; jHTitoneiim p.'i>ses from the 
leettim to the pasterior wall of the va-jina, about an inch below 
its attachment to 'the cervix titeri, forming the min-niiiiiinl jwiuli 
of Douglai and poiterior liyumrHtu of tin; iitirnn (Fig. 13(i), thence 
over the body of the uterus, and from tin- front of the cervi.\ to 
the bladder, forming the nleni-rfnirtil juiufli. On each sidi- of tin- 
Uterus it is stretched across the pelvis, furmiiig the lirnml liiiiniimt of 
the uterus, which contains the ro\nid ligament in front, the ovary 
imd its ligament behind, the Fallopian tube above, and a (quantity 
of vessels, connective tissue, .and unstriped musiiilar libre. The 
falae ligaments of the bhulder are the same as in the male, but aiv 
leu distinctly marked ; and the' rellections of peritoneum from the 
bladder to the uterus in fnmt hiis K-eii named the imUrlor liga- 
ments of the uterus. 



346 



THE PELVIS. 



[The peritoneum is to be stripped off the upper part «" ' 
the liludiler, but the recto- vesical ]iouch is iiut (o be intn 
at present. By »craj>iiig awiiy a little fut with the Iihik^^i. 
knife the jK-lvic fascia will be brought into view, but to Man 
it friiui tlie outside thorou;;hly the followin;: dissection mujt 
made. One dissector holding; the pelvis finuly, the nther is to ol« 
away the remains of the adductor muscles on the left side of th 
puhes so tt.s to expose the obturator extemus niuHcle, which mu 
theu lie cjirefnlly removed. Beneath the muscle will l«; found tli 
branches of the ulUumior artery, forming a circle arouud the foranie 
and lyinn upon the obturator membrane, which gives ]>ai>«age 
both obturator artvry and nerve at its upper part. On removia 
the fibtui-.it^ir membrane, the tibres of the obturator internu* muacG 
will 111- brouj;ht into view. With the saw a horizontal cut is now I 
be made from the upi>er margin of the obturator foramen intii I 
cotyloid cii\'ity, unci a similar one at the lower marj^n of 
oblurator foniiiieii, the extremities of the two cuts being about 
inch apart in tlie bottom of the cavity. These are to l>e joined 
a vertical cut with the chisel, and the piece of l)one having 
loosened with that instrument, can be removed with the Iwnf 
fori'i*]w. With the chisel and bone-foi-ceps the margins of tie 
obturator foramen may then be cut away so as to lea%'e only * 
ring of iKine. The rjhturatur internus lieing now fully exposed, 
should Ik- cjirefuUy detaclied from the adjacent structures, wid 
may then be reailily removed by grasping the tendon with the 
bone-forceps and drawing the whole muscle out through the lesser 
sacro-sciatic foramen. The outer surface of the pelvic fascia will 
theu be exposed.] 

The Felvio Fascia (Figs. 162, 163) consists of several more 
or less distinct planes, which are however in many places coD' 
tinuous with one another. 

1. The ohtiiralor fatcia (pelvic ftmcia proprr), the outer s' 
of which has been exposed in the dissection describetl above, 
spi-cial fascia of the obturator internus muscle, to the inner surfiirt 
■ot whiuh it is applied. It is fixed round the margins of the attach- 

Bent of the muscle, viz., to the back of the symphysis in front, to 
npper bonier of the true pelvis above, to tlie margin of the 
sciatic notch behind, and to the ischial tulierosity and the gi 
sucro-sciatic ligament and pubic urch below. It forms a 
(raiKi; of A I cock) for the pudic vessels and nerves in the outer w 
of the isehio-rectal fossa, and, marginally, it is closely related 
the deep layer of the triangidar ligament wluch bridges across 
subpubic arch (Fig. 163, 4). 

2. The faicia over tlie pyriformit covers the muscle of that nsme. 
It is continuous with the posterior part of the recto-vesicjil fascia. 

3. The recto-w»Uid faicia (Fig. 1<53, 8^ has a \iarietal k; 



-^ 




THE retVIf: KASCIA. 



347 



ing^The ' - aiii aiiil cotcyfjm, mid h vinri-nil liver invert- 

ami li: n the fwlvic vMccra. It U fiMxl in front to 

I back f>f Uif \<nhic lionc-.B nlxive tlir ori^jin of tlie levatores iini, 
ijjt« linwn lM»twren the*e nmnrli"* ii» far a» the upex of the 
j; twci roiindol fohl*, thr anltrinr triu 'jiuhfi- firot- 
Liu" "/ Oi* blmldrr, K-iieath which lie the tlotsal vein 

Pig. 16J 



'• (lou^ 




lh« pmlH, opening into llie pixwt&tic |il(:xu", ftnil the vesico-pubi^ 
luolo (lerivnl fruni the antt-rior wall of the Mtnlilor. LAtcrallj 
bIcn<U with the ohtunitor fusciu ulong u (.•nrvi'il fibroiw l*nd 
own a« the vjJiitt line, which cxtciida from the back uf the pubic 
the lochia! sjiine, ami givcas origin to the j;reuter purt of 
vator ftnL It covers the upper surface of the levator ani 
coocjic«u», and u reflet-led from these upon the prostate, 
•ml rectum, and upon the vagina in the female ; while 
orijr it ia connectiJ to the pyriformin fascia, and in tn>nt it 



fif. 182.— Ptlvie fueia aeou tram the outJiuie (dmrn by J. T. Oimy). 

Kxtrinal cutuncoui nerve, 
Piiu|iort'» ligaiueut. 
Saltan 111. 
Anirrior rrunil nerve. 

Ill iliiiciu uiukIm. 

lit femoria. 

, partly rvmorecL 



1 1. I'olnr faacio. 
1*J. PcfitintMia muu'te. 

13. Ubturvtor fucia. 

14. Gimtwmat't ligament. 

15. Pudir veMcU Mid nerve in elieat]! 
of fairia. 

I<1, Olitiirutar vouela and nerve. 
18. tatcinl origin of levator ani (white 
liiip). 



348 



THE PELVIS. 



in contact with the ik-ep Uyer of t)ie triiuigular ligUDCnt (I 

114, 12), 

4. The uehio-Tfctat or anal fnuia is a thin meiulirane coTeli 
the outer or perinaeal surface of the levator iini, and ia il<THi« 
from the obturator fascia (Fin. 1(S3, lo). 

The derp triangular ligam^it, which has been previonsl? 
scribed, might be incluJeJ amongst this system of fascia! ; for 
stretches across the pubic arch, and blends at itn attachment to I 

Fijr. 163. 




bones with the obturator fascia, of which it may be regarded a» • 
continuation (Fig. 114, 20). 

The hchio-rcctal fossa is an interspace bctwei-n the ischio-rectal , 
fascia and that part of the obturator fascia which lies below the whiti 
line. It is boundeil above by the angle of divergence of the t» 
fasciiB, and sends a forward extension above the jwrineal ledge ne 
as far as the pubic bone, and a jiostcrior extension over the gn 
sciatic ligaments (r. p. 232). 

Thus, the levator ani muscle is seen to be enclosed between I 



Fig. 163. — Soolion of pelvis to thaw the pelvic fngcin from the (rout (drawn by 

J. T. Ciniv)i 



1. Obturator inlcrnud. 

2. Ditto fascia attached above t*) 

inner lip of iliac crest. 

3. Levator aui. 

4. Obturator fascia. 

6. Lateral ligament of bladder. 

6. Obturator fasi:ia, tpUtliog below to 



enclose piiHic veflsela and 
nerve or the penis. 

7. Cupaule of |mi»tHt«. 

8. Itccto-vesiciil fa«?ia. 
y. K<ctiin) (cut). 

10. .Vnal ftacU. 



SIDE VIEW OF PKI.VIS. 



S51 



The B«otTun (Fig. 164, lo) Iiuk b*eu dwrrilieil t>n \mf(v 304. 

[The left veoicula Mniiualia kIioiiUI lie iliMt'ctnl oiul ita |HnitloQ 
noted, aiid th« va* defeniw and uietw of thr Irfl »ule are alw 




ed out ; till- recto-vwicnl ])uik'Ii uf pcriUmouiu U lo 
oiH'n iilong till- Kidtf, »<i tlmt lU cxttut iimy \w tiilly aji- 



Fi£. lis. — Side Tivvr of male |h>IvU (frmii Mm liiu/ii Surgical Aliatonijr). 



ftarrutn 



rfpry. 
turn. 



II (cul off). 
■ I bv pcritdui'um. 
■Udui <iuv'i\ rtvd by peritotieiim. 
Va« ilrfcreiu. 

mUi. 



Jf. CruK [irnu. 

•1 rri'lhrii n. Bulb 

1'. S|iliiiu'trr iiiii. 

«< i:.M.>x. 

U. S:uriv4(Tin!ir lijpinicnt. 

.S. Iiitentiil lliiic nrtiTV. 

'1'. Sftrltil lirrVL-H. 

V . I'j rifnnmi. 

W. I'uilu uitirj olid iiiTve, 

X. Truiij^uLir ligamiiit (out). 



»50 



THE PELVIS. 



about one inch from the lower border of the jiubjc syinphyi 
This is the portion of the urethra openeil by the deep ini'iiionj 
lithotomy, and it should be noticed how much it3 poiiition 
vnry according to the movements of the staff, — whether that ii 

Fig Iftl. 



T 



'6 l« It 

luent be hooked under the pubic arch or depressed towunb the 
rectum. 

The sheaths derived from the recto-vesical fascia should l>e usonl 
on to the prostate, bladder, and rectum, and theste organs an* tD U 
cleaned, and their relations to one another noticed. 



Tig. 164. — Section of pelvis to the Itft of the medinii line nt Ih* pabc*,i 
through the middle line of the ucrum (drawn by J. T. Uruy). 

tiiin), itnd Cowper'* gland of ( 
left aide. 



I . Section of left pubic bone. 
U, I'eritoneuni on bladder. 

3. Left oru« penis (cut). 

4. lU'cta-vc«icHl fiuciii forming ante 

rior ligaments of bludder. 

6, Part of accelerator uriuii-. 

6. Superior layer of irianguliu- liga- 
ment, or pelvic fuiiciu, continu- 
ous with the capsule of the 
proetute. 

7- Inferior Ujer of triangular lii;*- 
ment, or deep periuaiU laeciu. 

Between 6 and 7 are «.'cn the follow- 
ing : — mcmbrunouh iirethrii, 
deep muteles of urethra (,iiu«t- 



8. Vn« defereni. 

9. Bulb iif urethra. 

10. Iteclum. 

11. Cut edges of acrelentor anxu* 

nnil tmn.sverBut perinuii. 

12. Left ureter. 

13. Betlet-tion of deep Uvcr of tupir- 

ficiiil fujcin round tnumv 
perina-i. 

14. Left t esiruhi 4eiuinalis. 

15. Cut edge of Iwnlor ani. 

16. Itectuni. 
U. PiWkUtu. 



SIDE VIKW OP fKI.VIS. 



351 



Tlie Beetam (F\^. \6A, lo) li«i> been ilesmbed on jjari- 304. 

[The left resiculn e«miiialis fihouLl lie itiMccUd lUiJ iU punition 
noted, and Hxe thh dct'ercnt and iu«Ur uf the left side ut Also 

Fijt. IBS. 




i>e iracrd out ; llu' ieiU>-vi;*irjd iwili'h ol prijiuiicMiii i-^ 10 
be laid oiifu along the fide, »i> llmt it* vxtvnt nmy hr fully iiji- 



Fie. \0S, — Sidd rievr of male prlvu (from Mueliwi't Surgiral Anatoiux]. 

A Sii'lilin. 



BUuM« r mil 
V» drfcrxDi. 
Cntcr 

TaiciiU Kminiilia. 
tie Mini. 



trn (cul off), 
ii by pcritonrum. 
iciiemlbr jicritoneuiii. 



N. Cni* |M'ni*. 

0. rrpthrii. o. Hull). 

F. SiiliuicUr ani. 

Q, C'<H'rv\. 

K. SiirriHwiutif ii;cuni(itit. 
8. Inli"niiil ili:ir nrton,-. 
T. Snrrul n>nc». 
r. r\rirtiriiiiii. 
W. I'urtic nrtiTV lud iiiTTe. 
X. Trlnngularllt^uiui-nt (rut). 



852 



THE PELVIS. 



The Bladder (Fig. 164, :) varies in position according toiSi 
of diitfiisioii, lying Whiiul tlie pubic bones wiien empty, bat i 
from tlie pelvis into the alnloinen when diAteniled. The 
tufi of the bimliler is the conuiiencenient of the proAtiitic i 
and it* " tipex " is icpresentej by the attachment of the 
In the vertitjil pf)«ition of the subject, the part which )« in i 
with the jmbic bones is the aiitero-inferior trail (3), and ia uLtiuct 
horixontal in position. Tliis surfitc^ is uncovered by peritonenis, 
. uTid is separated from the pubic Ixines by u space called the 
Jktzii, which in occupied by a maj8» of fut continuous with the 1 
I>erit<inexd tissue. The upjirr tnrface (2) is completely covenxl 
]>eritoneuiu, and is in contact with small intestine and t>oinetf 
also with the (sigmoid flexui-e. The pjiUnur turfact (4) lo 
btickwanls and usually more or less downwards in the erect ; 
fion of the btjdy, and is seen to rest on the second portion of 
ivrtiuii, but sepiinited fnjm it by the vesiculae seminales and vj 
idefen-ntin. The lateral fiurfncr* (8) are crossed by the ohlil«n 
' hyiHiga-stric iirferiei*, which pass to the abdominal wall near 
unichus, and limit tlie line of reflection of the peritoneum ; and I 
the vnsa dcferentia, wiiich run downwards and backwards on the 
jielvic side of the oblitenited hypogastric arteries and on the ve«iiMl 
side of the ureters. The ureters (12) pierce the blsilder at th» 
junction of the jiosterior ami lateral walls, al>out an inch nod n b«lf 
above the liase of the prostate. 

The ]>rritinii-u)n is reflected from the second portion of the recto 
on to the back of the bladder, about the level of the entrance oft 
ureters, aiiil is then continued over the upper surface and up 
portion of the side-s of the bladder and over the iiruchus to I 
alxloiuinal wall, leaving; the i-est of the organ covered only hy i 
investment of ischio-rectal fascia (Fig. 164, 2). 

It should be noticed how much the extent of bladder uncoveK 
by peritonexun, both above imd below, depends upon the <liste 
of tlie viscus ; since, in the contracted state the antero-infei 
surface is in contact with the pubic bones, whilst in the di»tend^ 
condition it rises above the bone usually for a distance of t* 
inches or more, and lies against the posterior surface of the antiir 
alKlominal muscles. Thus tapjjing above the symphysis may geiien 
be effected without injur)' to the serous membrane, but as the ' 
toneal fold occu-sionally fails to rise the o|H:ration is not free I 
danger. Tlie depth of the recto-vesical pouch will similarly U 
found to vary, the peritoneum reaching nearer to the pro.stote when 
ulder is empty than when it is full ; consequently the opera- 
tapping by the recluia cau W ouV's wXvlVj utuicTtaketi wLa 







SIDK VIKW OK TIIK I'KLVIS. :)63 

the bladder is distended. Tho avrm;^ diHtuncc uf tlie rccto-veaicul 
poach from the anus in sSA int-lieii wiieu both luctuiu ami bladder 
are empty, and 3j inolicM when tlu; hliuldvr in diNtcnded (Oripps). 

The left Ureter (Fi};. l'>-i, 12.), (IcywiKliii}; fn>in the kidney, i" 
containe<l in tku n>ut uf the [Misterior false li<;aiii<-iit of the blaildi-r 
(or in the root of the bniwl lipiuient in the f<-niali'.<, and now- can be 
tmced beneath thf jicritiiueiuii to its eiitrani'u into the fundus of the 
bladder, at u {toint lielow- and iM-m-ath tin: posterior extriMaity of 
the vesiculii seniinalis. Its relations are described on p. 'Mi. 

The left Vos DefSsrens (Ki;;. I<i4, 8) eun be traceil from the 
testicle, and luui lietn neen to turn liown into the ]H.>lvis after 
leaving the inKuinal cunal, hooking aniiinil the dee]i epi<{iistrii- 
•rterr, and to tiie inner side of the external iliau artery. It is 
now aeen to wind over the ]M>Hterior part of the side of tlie blailder, 
crowing the outer side of the oliiitenited hypo);nslric; itrtery, and to 
be continued Iwneatli the ]M>rltoneuin to tlie liase of th(! l>Iadder, 
where it pa«ses to the inner side of the iiivter above tlie ]H>int at 
which the latter piervf^s the bladder wall, ami to the mesial side 
of the vesicula i>eniiiialis. It will 1h- al'lerwarils trai'eil to the 
piostatc. 

The Prostate Oland {Via- l<'l< 17) ■'* "ow >eeii in fntnt of the 
bladder as the ]iai't lies on the table ; but when tlie boily is eiirt it 
i« situated bidow tlie bladder, the neck of whlili rnrn-ipiinils to the 
enlarged boM of the (;laiiil. Its lon^' axis is verlii'al or inclined 
slightly forwanU at its hiwer eiiil. The n/uj- touehes the di-eji 
triangular ligament (6) ; tin- iMintrn'or imll U in runtjicl with the 
termination of the Heconcl (Hirtioii of the rei'tniu (or, uecoiiliii}; 
to some authors, with the eonimein'emeiit of the third part »f tlie . 
gut) ; the nntrrior irall lies hall' an inch Is'liiml the lower half 
of the pubic tiyinpbysis, but is se)iarate<l iVoni it by a ]Mirtion of 
its capsule, a plexus of veins, the ]Mibo-iirostatic li^iaiin'iits, and the 
Teaico-pubic niiuculur tibre:) ; the niilm are in contait with the 
anterior bonlers of the levatures aiii. It i> eiiclnsei! by a priH-e^s of 
recto-vesical fascia which forms the mjiguli; In'tween tin- lay<-rs of 
which lies the large jirostatir ]>lexus of veins. Structurally it 
is composed ]>artly of glandular, partly of muscular tissue. The 
urethn passes through itx substance nearer the anterior than the 
posterior surface (see also p. 3fiH ). 

[A tianinrcnc rut is now to lie ma<h- at the bi.ltnm ■>!' the rccto- 
Tesical pouch, which will allow the bladder to be drawn forward, 
when a little direction will ex]H>JM! that jiart of the siirracu uf the 
viaens nncovercd by peritoneum which lien over the rectum.] 

m. \ \ 



354 



THE PELVIS. 



The |K)rtion of the bast- of the bladder tiiicuveretl by pt-rit 
is ti'iangular in shai>u. It is bounded at tlie sides I>t the ta 
tUfcn-iilia and raietUir aiiiiinaie*, the latter being external to tl 
fonuer ; above by the reflection of peritonenni at the line of 
entrance of the ureters, and the apex is at the back of the \)T0»U 
It is here that the bladder is opened when pnucture<l from 
rectum. 

The recto-vesical layer of pelvic fascia um now be traced betve 
the rectum and bladder (p. 347), giving a coverin); to those orgi; 
to the prostate, and to the veniculm seuunales. 

The VeBiculse Seminales (Fi(>, lfi4, 14) are two branched 1 
ounvoluted i*acji, plarcd between the fundus of the blaiM' ' 

rectuiiij l^'iiJi; exlerually to the vesiculse seminales, aTid 
to enter the baxe of the prostate close to the nic<lian line, \^^>j 
in situ they are uboiit three ine}ie.s in Ien),'th, somewhat expand 
at their posterior extivmities, and are broiul above and narrow nh4 
they approach the vasa deferentia at the base of the prostate, 
superior extieuiities, which overlap the ui-etcrs, are about tiru 
inches and a half apart, and are covered by the anterior layer of tiic 
peritoneum of the rectu-vesicAl |X)uc}i. The branching ia not riAble 
until the bodieK are dinsccted. 

The Vasa Deferentia become somewhat eidarged, sacculated t 
jircsent short diverticula on dissection where they pass beneath 
liladiler betw<:en the ve.sii'idiu seminales, but are verj' narriiw wh 
they join with the ducts of the latter to form the conimou ejacuJa 
ducts (Fig. 17:!, 12). 

In the Female (Fig. 1 78), the short urethra will lie seen to ; 
obliquely downwaiils and slightly forwaiils from the blnddt 
jiiercing the triangular ligaments ; and immediately brlow 
behind it is the viigiua pas»iing up to the uterus [which must be 
in position by a siring i>aseK;il through its fundus]. The rectn 
occupies the Haiue position as in the male, but is rather liit\ 
the peritoneum will be seen to pass from it to the jxjsterior 
surface of the upper part of the vagina, 10 form the recto- vaginal 
pouch, and is tlieu retlected over the bo<ly of the uterus to fona ihc 
utero-vesical pouch. 

The recto-vesicjd fascia gives coverings to the rectum and 
This should be defined, and the latter canal may be laid open 1 
the side to study the position of the on uteri. 

The bhidder, urethra, and other pelvic organs in the femalA I 
described on p. 376, rt seq. 

The viscera of the pelvis being dtiLWu dxwu to tl)« I<ft, tlw 




THE INTERNAL ILIAC AUTEKY. 355 

internal iliac veswels and nocral ]>lexu.s of the right Hide can be 
examined ; the position of many of thuui on the left side having been 
previously, an fur as piMsiblu*, ar-ct-rtained. Opiiortuuity luuy be 
taken to trai-e branches of thf KyniiNitlietic nerve to the Bides of the 
pelvic organs.] 

The Internal Iliao Artery i Ki){. 1 (iti, 4) in u branch of the 
common iliac, ariRing opftuxite the Ium1)o-iuici-aI articulation, and 
immediately passing into the pelvin. It is usually about an inch 
to an inch and a half long, and is Hniallcr than the external iliac. 
In the fcFtus it is pro|iortioually much larger, us the hypoijattrie 
artery, the direct continuation of the common iliac in size and 
direction, passed forwards over the bladtler to the umbilicus ; but 
this is now ironverted into a libr>us cord, which however is pervious 
for a short distance, and thus gives branches to the bladder. The 
intenud iliot; is criMsed at its origin by the ureter, and closely 
covered by the peritoneum in front ; Ixihind it are the internal iliac 
vein, tlie sticrum and the lumtN>-sai:r.il cord, and in the female the 
ovaiy rests in a depntssion (fossa 4ivaricaj between the artery and 
the vein. At the upper l>order of the great sucro-Hi-iatio notch it 
divides into antrrior and jmtttrinr trunks, which give branches to 
the viscera and to the insiile and outside of the ]ielvis. 

Braaehea (Fig. lOn). — From the anterior division an; given oif 
three visceral ami thn^e ]>arietal branches ; from the posterior 
division three parietal branches. 

Anfrfiin' Ih'i'isinn, 

vi.«>~i ( Superior vrni-nl. ...... .... / Obturutur 

bnachc I Middle h»m«rrh..idal. •'"""'"•■''• ) Sciatic-. 

( Uterine \ Bdditioiinl in feniulr. Tlic ruRinuI cormponding 
) Vsipnal ) til the int'eriiir vcaiinl in tliv male. 

Fmierior Ifiritioii. 

I (iluteul. 
Parietal brundieM. | Ilio-lunilmr. 
( Lateral wirnil. 

1. The Superior Vttieul (7) arh-ries are snuill brunches from the 
nnobliterated portion of the hypogastric artery, which are distri- 
buted to the upper part of the bludiler. A muldle vniciU branch is 
aometimet derived from one of these, and from another or from the 
inferior vcucal is derived the arte-nj »/ the va$ drferem, which 
aeeaaipaniea the duct to the testicle and anastomoses wiOi VW 

k .\ i 



d5ti 



THE PKLVIS. 



spermatic artery. In the fi-male this vessel ia repiewnted by 
fiinicHUir artery to the rouud lijjumi'nt. 



Fis. 1156. 




Fig. 168.— Side Tiew of female polvin with 

8avngr). 

I, 1. Spermatic or ovarian iirter;r. 
'I. Kigut ureter (cut). 

3. External iliac rcswis. U. 

4. iDtemul iliac artery. 10. 
6. Epigaatric arterv giving off au ob- 1 1. 

turator branch. \'i- 

6. Porterior trunk of intcninl iliin' IH. 

dividing into elulviil, ilio-lum- H. 

bar, and latenil Hacntl branclii'8. 15. 

7. Anterior trunk of intcniitl ilino Ifi. 

arterj" giving off suiiorior 

veaical and uterina artcrica, n. 

and ending in the oblitoraled U. 

hypogaatric (cut). 0. 

8. Uterine artfrv amuttomosing vrith T. 

the ovarian in the broad Uga- 11. 



intcnuil iliac artery (altered I 

ment, and giving ulf a 

bniucb. 
Obtnrator artery. 
Left ureter. 
Olituruliir iutrniUK. 
Sncial plexu4. 
PuJii; iirtcry. 
Sciatic artery. 
Levator ani 
Infi^riiir vtaicnl and Bin 

hu'iuorrboidal arleriea. 
Bladder. 
II tenia. 
Ovary. 

Fallopian Tube. V. Vacina 
Um^'om. P. PuhiB 



THE INTEKXAL ILIAC ARTKRY. 



357 



The Itifrrior vnifiil lUiil 3, Middlr. hirmnrrhoidal (l6) iirt«rlc«' 
fimlly coni«« off tDgftlicr, mui nfv clihtrilmted to the j>o»t«rlor 

f*c«? of the Viladil'T, the iipwUti', lliv vwh'iiIm ■■■!>•<, nnd tb* 

iir«ut jiortiou <il' the n'i.tmii. The iiiiclille I Inl artury 

noses with the sujerior hunudrrhniilal liniD'M "i ilio inferior 
ntcrie above, and witli the inferior hiciiiurrhoidul brunch of the 
~^nidie »rti?ry bcUiw. The art^Tios of tin; bliidder anoatoniOM fr<^cly 
wilii one (Uiotlier, nnd with lli<i»i' im the oppoxita «ide. 
^4. The t'lrrini (^) Aiiil I'df/iw/i/ (U'lrrii'M »np]>ly those urKiiiis, ihf 
rinc jmwln^ in tlic \m»v of thv \>u>ni] iiv-itini-ut fta fnr as the oervix, 
lllen runniuj; uji dutw.' lo the »idi- of tho iMviy of the urKnn 
I'll in,' brandiKH to ita unteriur and posterior mrfiwc*. It 
lit the KUjirrior anjjle of the uteriia with the oviiriMi 
Mi ;.<iii' "i-n Hrt4<rip«, and infiTiorly with the vaginal. 
Hi. Tbf OUunUur (9) Biti'i-y iiino<r» directly forwanls, below the 
p1 of the iiervi' niu\ iilxivi lluil uf ihii vein, to the > ' '■■"' r foru- 
tLrtiiiv'h which it dmippviir" with tliu tl'.Tve, afi. If a 

•11/ ,1' tile Unw, un<I iin ilmc ininrh to 

ill The piibio brundi anaxtonioxo* 

I liu iK< |i rpi>,'ru«tric. Tht; iliitribution of the 
U- tho pelvis liiH Iwrn already seen on thtf 
lit »ide, but nmy now W followed o\it on the li^ft «iili>. 
r'hen the obturator ariw* fnmi thu epi^nvitrio artery, there U 
craU) a •4iiaU bnitich luanlng in thu proper po«ition with the 

„.i^.- I'r p. lift). 

i^^&iidT.lbe ^t(r<ii:(t4)art«riea can only <>« keen 

.. ..I..., .1 . j„.ivi«, QM the y lie on the pyrifumii* 

■A ihronjjh the lower port of the 

low that nin«ck'. The pndio in 

. unci It little in front of it, but the 

i^ntl nlaiive poMliuii.-. ul ihi' vei«id» vary. If theperintonm and 

bulIrK'k huvu bpeli ili'UM'i-trd, thf opj.>ortnnity may W' tttk«n to 

the Dciutic uriery lliMuxh the ^rt'ut itaero-«ciutic fomnieu to l(« 

(ribution outside the pelvi*. and to follow tin' pudio in its course 

und the spine of tlie itohiuni, und through the Ie.s«rr fornroen to 

perintcum, where it will l>o -een lunninj; clo«« to the margin of 

' ox pabi« (Fig. 1 1 Ti, 9). 

I Tie t hi-ott poiiAUJ Lnuidics frutu (h<* PoMtrior Divitimi of the 

umal iliac artery (Fig. 168) uri<, the gluu-al, the ilio-lumbar, and 

lateral »acnil orlerieii. 

Tlic Uluiral nrt(^r}' ia.ji thick trunk, disappearing at once 

T part of the great sucro-iciulii: foramen, between 

curil and the fiist "aiTuI nerve, and aV>oN'« \.\vit 



THE INTERNAL ILIAC AKTEHV. 



339 



pynfoRoiit. 
the inti'. 
2. T 

dw pkux> aJi.1 ill.. 

^Tidei ttit<:> 1 , ■ 

tamtxir'art' 

and 2, na < 

■BMtamosing with 



It •uprplia* tnuafulnr hmnchv* ami u iiutritioiu lATlory In 
' ' !H (liKtrihutt'il to tlif lititliick. 

% 1 1 O.I ]Ki»^-« iiitu tlif iliuu fcMiuk l>euvath 
11^ tlie liimliotJicrul u-urtl ; ami tlivi}^ 
li wliich ntiiu<t(imiM<is with ihi; In 
;i« and givi'« utf II •ipiniil hniiich, 
-ll|>I>lir» till- ilijjrm. Alitl tlio Imnt', 
thr iibtutatnr, finninitlex ilinc, iiml liimtwr 



,u. {,. 



.t .T.. 



irterj' 

t>ir- »i 



I 



■ttodea. 

3. The ImUtuI mi-ml artery (13, 15; ( often ilmiblf) livsufQ'l* '■•» 

' -Msilly ti> tine aiu'rul furumiiui, iu iliu 

lib the nrtery of the u|j]><milu eiili- 

1 In ii» ci)ur*it it givi-» 

', Hnil n'lioh the niu«(:li-» 

111, while iilhtTH Hujijily thi- 

wril im thi' "Hinii niTVi'*. 

i^ Ui lh>' liranrlitrx wf lhi« iutcrnal itiiur 

nil iliiir win. with t)ii< <-xc'C]itii>ii of the 

I uccaHiuuully llu- lati-rul 'Uicnil vi-iuH, whicli jmn 

- veint. Till- intrrnul iliuo M-in (Miaaen lH-n«uth il» 

iunian iliiic rrin, which nn thi- left siiln aloo recetTM 

a1 %cin (Kig. IflT), 

Ma-Mrr iind r^rtum art- now tu !«• ilruwn out »f the rwlvii 

winch it will li«? neci-iinary to divide the 

ii'l till' riifln-vi'ilcal luMT "f privic I'liKciit ; 

iiiti \ K w tht> Htructiiri'H wliii-h rloMc tin- lower 

1 of thf i«'lTi>-, ] 

Tbn Floor of tho Pelvis (Fig. tni)), vrhich i* <lirecte<l forwnnU 
tad npwvr:- m<1 by the fnllowiii^ Htriii-tiireH, In fn^nt, thit 

ktmtonN •!■' 'wii kiiU'x Mend in the middle line, iiup|><jrtin^ 



lU. Ulutrttt veil), 
lliu-luinliiir vitin. 
l^tiTiil wrnil rriii. 
SiiatK' vi-ln, 
rtiilit- \mn. 
Dbliiniior rein. 
Kpi|tii>tric irein. 
I'trrin** vrin*. 

Vim ' IMIIt. 

lit I 

Dnls ...ry. 

Vein to ruuuU lii;ainvnt. 



> fimiiii^Bin. 


10. 


..umaSh*. 


11. 


' -rlcn. 


li 


' .'titumor Bwn^ 


1.1. 


i-U(«alaMaaiB>IrlDK. 


M 


'.t^cuaml mtru. 


15. 


' (rriia lu—iitfit Brier; 


III. 


-silica itias vtrri**. 


IT. 


I ft cilmul UUe artar) . 


18. 


' ranrm inlMor. 


IB. 


i:> oil Tftii*. 


•jn. 


■ " I ■ ■.■■■.,-!, I : . '-.- 1.. 


41. 



lolani*! uut tataj \mi}. 



23. Falliipiuii rciiu. 



S60 



THE PELVIS. 



anil closely connect«d with lliu iwlvic viscen*. ImmetJi, 

these, aiid separated fi-om theni only by a very narrow fpitt 

of cellular tiesiie, are the two coccygei muscles, suppiirtcil 

Vig. 168 




Fig. 168. — The iliic uterics nnd rcin« (from Bonainy mnd Beau). 



1. Vena cava 1 4. 

2. Aurta. In. 
:<. Right i^ommou iliao artery. 16. 
4. LtuadratuH lumbonun. 17. 
d. Right common iliac rein. 18. 
fi. I.efl common iliac artery. 19. 

7. Middle racrul arttry. '20. 

8. Left common iliac rein. L'l. 
0. Middle mctkI vrin. '2'i. 

10. Ilio-lumbar artery. 'I'.i. 

11, /.eft intcmnl iliac vein. 24. 
V.J. Jx^ft intcmaliliai' artery, '26. 
13. Jjteral sacrul artery. 'Ki. 



Circumflex iliaii artery. 

Lntcnil siiiiTil artery. 

Left pxternal iliac artery. 

Pyiifonni*. 

Left exteiTial iliao rein. 

Pudic vewela. 

JllO-USOOI'. 

Small tiacro-itciatie ligament. 

Obturator artery. 

Great tacrii-x'iatic ligament 

Horizontal ramus uf pubet- 

(schium. 

V'vlTOK. 




THE LEVATOR AN I MUSCLE. 



861 



iht nacro-jiciatiii liK»n>cntii. The (Treat »«cro-«cl»tSo 
itmin*, which lie atmve the wwcyKt'i, ar« oci-.iipiml by the pyrifortui* 
anil UiB glutro] re«(«!l» and nervo* ln«vo the j)elvM at the 
irdiT of ih»w nmsch-s, niiJ the sciatic anil pndio lielow. 
I.ev*tor AbJ Muscle fFiji- 1«». 4) t^kra ita origin from 
ck fif til.' .lA piiIiiK, fnmi the front of th<' spina of the 




Jiiiiuii <uh1 b«twri>n tln^n-. jKiinta its Kbrcs are uaiiully attached to 
c uAifr line ui the oliluriitor fascia, M:i>n in tlic dinAcction of the 
seiu frotn without (Fig. ICSi), but ocowionnlly the flbrea ari*e 
EKO the pelvic fiucia some di«tanc« above th« wliite line. Tb* 



f!(. 160. — Floor of feniule piilviii (froni Suvnge). 

' ' ' 8. Cix'cvgcu" muwle. 

9. • Wliili- luin' of pelvio fiuKla. 
Li^ 10. Hxialii' uiid pujic ycmtIs 

ncrTrii. 
I). I««i'r Hirro-MrUtic ligament. 
BD* muKle. 12. Front of urrum. 

lofnKtvm. I'A. I'ynforniit muMle. 



•n<i 




362 



TQE PELVIS, 



onterior fibres puss by the side of the prostate in tlie uiuJ«,| 
the vagina in the female ; the niiildle tibres blend with 
tudinal fibres of the reetiini and the external 8{i}iiuct«r ; awl 
posterior fibres partly unite with those cif the upposile »idr in I 
median raphe behind the anus, and partly urv altache<I to the ip 
of the coccyx. It is mijiiiluil by branches froiu the 4tli »of.ii 
nerve, and by a branch frf)m the anterior perinujal nerve. 

The Cocoygeus (Fig. 169, 8) is u little triangle of 
muscular fibres having its insertion into the side of the cooctj, 
and its origin (the apex of the triangle) from the «pin^ oJ 
Lichium immediately above the attacbmcut of the levator 
from which the muscle is sejiarated by a narrow cellular inleni 
The coccyfjeus is intimately connected with the lesser 8«<:r»-Mii»tl 
lij^'anient, which has nearly the same attachnientii and lies e\ter 
to it. It \9 supplitd by a brunch from the 4th and Sth 
nerv'es. The levatores aui and coecygei raise and .support the Ho 
of the pelvis during expiration and abdominal expuUive actions. 

The Obturator Internus Huacle (Fij;. 170, 19) ha- 
destroyed on the right side, but un the left side of the pelvia may 1 
seen both above and below the level of the fascial ori{{in of til 
levator ani. It arjs" fwm the posterior aspect of the rami of 
pubes and ischium immediately in front of the thyroiil foranut 
from the inner half of the pelvic surface of the obturator membmne 
and from the surface of bone behind the foramen as far as the 
sacro-sciatic notch, and above it as high as the ilio-jieclineal lin 
The fibres end in a tendon, which turns at a rijjht angle arnun 
the margin of the lesser »acr< (-sciatic foramen, to be innrrttil 
the fore part of the upper border of the great trochanter of th 
femur. Its deep surface presents tliree or four linear groove* u> I 
winds over the edge of the sacro-scialic notch, and the bone i« he 
encrusted with cartilage and lubricated by a bursa. It is tupplim 
by a special nerve derived from the Junction of the liimb 
with the first sacral nen'e. It is an external rotator of the feroo 
and a feeble abductor when the thigh is ilexed. 

[The pelvic viscera are now to be removed by carefully detnchiaa 
the urethra and blaitderfrom the pubicbones, dividing the levator on? 
and severing the slight connections between the rectunj and coccr* 
The whole of the urinary and genital org.inH should l>e curefulljr 
jireserved for after-exaniinalion. The sacral ner\'e« can now mi 
dissected on the right side of the j)elvis, and in oitler to see thea j 
clearly it will be well to remove the remaining branches of th»l 
internal iliac arterj'. All the bi-anches of the sacral nerves »hoiil(t [ 
I»e preacrved, and care should be taken not to remove the gongli 



THE HAC'KAL I'LKXUti. 



conl and h.vf^"'-''r' >■! — - < -i- viripntln-tic Thi*. upiwr imcnil 
nerves will • ■ : om thr runiiiiitiii. l»ii the tiftli j 

•»cr»l and Hi- -. ...f !.. fotiuil iiiercmg the iiMcygmw 

laa&cle close lo Uie etde of Ihr coccyx . | 

- . Tal Plexua (Fi({. 17t') i« fi>riiietl liy tin- union "f thi- 
tij iM.i i>irt of till- foiirtli iwicriil ner\e», willi llii' liimlx)- 

s-i rth uiid liflh lumlMir.ucryv", *!*'«l' 

ii ■ !v1». Thf wvi-ral ncrvi'ji, ii» llicy 

leare the sacral lunumim, nciivi: brAncluiS from Ibt jjatiiiliHto'l-HiTj 
uf til.' -i lupaiLclK- 'III their iiiiicr hIiIii, unil thi'ii, lyinjj on ihe 
[•} iiiUKle, ihey unili- l<i form I'nc liirjjn Mat Iminl. Tliii 

pu-- ^ - .....^iijjU ihe sreat »acr»-i>cialir furutiii'U iiiliiu'difttcly uWovc 
the leaser Mcro-w:uitic li<,rauieut, aiuL, hy IwikiiiK at the uutKidv of 
the prlviB, the 4iia«ector will Im' hIiU^ to tev tin; three uerve« itito 
vhieh it divide*, viz., Qnt&t Sciatic, Snmll Sr.iiitic, and Iiiterniil 
Pn ' 1 the piidic ncrvo limy In- tmred ar<iiind tlw i.iiiiir of 

til I and through the U-wer xai.To-siiifttic foranim to the 

ftrrinrhfii mthin the Prlru. — A cou]iIe of braiichen urf yivcu to 
t'., lit, cither from the plexus or I'nmi the Bocml n«rvi<» 

Ik- iinitf. The ni-rr* to the Miiratnr inteniuf (i6) ari«"M 

at the point of union of ihe lurnlio-sacial with the llr»l wicnil nerve, 
and, ly»nj( on the anterior mirfai-n «'f thu (ilexus, piw»e!t with the 
pi»dic iierr« throuj^h tlie uacro-w-ialic foniinina to th« inner mrface 
of tiie niUM-le, nupplying iti iU courke the geinelliui itn)iorior. Tho 
nerrt to tkt ipiadratiij from the lower part of tins plexua, c)r wiuie- 
ttaes from the i^reat sciatic nerve, passes out beneath ihul m-rvo clone 
beliiiul the hi|vjoint, and supplies the articulation and iiiUM'.akr 
twigs which enter the deep itiirfa>'i-9 of thr quadratUH and the 
g«iiieUut> inferior. 

At tJif upj>er lunrgin of the givat sacnmointic foriinien will he 
Mien llie tuperinr glulenl nmv ( 15), tierived fimii the luiulxmai-ral 
cord and one or two of the upper iturnil nervcB ; it imiweh out alMJVe 
tlie pyrifonni* with the gluteal artery, supplying the glutei mcdiun 1 
and minimus, but unlikr the vesstd d(M-s not give any uuiierKeiul 
bnuich to the gluteus niaxiniuK The >»i/criur (//u<«>a/ nerve to the 
gluteus maiimux may sriiwi either from the plexus or from the lesijer 
idatic iMTvc. 

Below thr plesu« are the braiicketi of the other sncml ncn-ea, 
Tliese last cat! wddoiii be made nut well, xince the nervex thciiiaelvfis 
oie Very amall. and are nurrDUinled liv 11 quantity of tibroU« tissue. 

From the 4(A Sarml nrrve a brunch muy Ix* traced to il« junction 
iritb tbe ML aerv<^ abU buut the 4lii oUo urv dutivtid tUceral 



364 



THK PELVIS. 



'hranrhrji to the bladder niul ructuiii, wliicli coiiimitniuat« «ritll \i* 
sympathetic, and muscular brtntthet to the levator ani and coccygtu* ; 
as wt;ll as u hanaorrlundal hraiteh wltich pni«ea through the ItvaDt 

VSs 170. 




Fig. 170.— Side view of the norren of the pelvii, the vitcer* barinc b«s 
removed (from Hir«chfi-ld and Le»eille). 

13. Obturator nerve. 

14. Flint 8rti;nil nerve. 
1.5. (iluteiil nerve. 
IC. rvriforinia of left tide (out). 

17. Obliirutor Hrtery. 

18. Scinnii a;ii'nil nerve. 
1!). Olitiinitor inloruu'. 
■JO. I'vi'ifiirmiK of right <ide, 
'21. Xcrve to levator ani. 
22. Sucral plexua. 
'U. I.eviitor ani (cut). 
24. Tliird xairal nerve. 
ill. Bulb of uruthra covered byMMln- 

ftVOT \vt\iuc. 



1. Abdominal aorta. 

2. Gangliated ennl of Byiupathetic 

(leftside). 

3. Genito-eruial ner%'f. 

4. l.<^ft comiiiiiu iliac urtcrv. 

5. lUglit rdiiiiiion iliuo uitery. 
C. Irfft luiulKP-aacnil cord. 
7. J'ioai iiiueole. 
H. Gangliuted cord of fiyaipnthetic 

(right side). 
9. Internal ilim: artery (cut). 

10. Cluleiil iiitfiy (cut). 

11. Right I'Mi'iinil iliiit artery. 
VI. Kight lumbo-naural ntrvc. 






lU mutde Htitl the cotcyKviia, to the pi'finiBUtti, to 
>:nial »pliiticl«r. 

•ral nrrrr cuniniiinicato* wilL tlif <ltli unil llie coccygeal 
rTuinntu« tijr ptercing Uii- coccv(;cufi muMcle, which it 
ach ihr nkin over tbn biu;k of the coccyx. ,» — 

lal ntrrr (fSlh) »Uo cmrrgoi from the lower cml of tlia ff 

ud pleice« th« coccygrxui niiixi'le to entl on tho liikrk of 

ed Cord of the Sympathatio (Fi);. 170, 8) tiiuy 

_i side of llic- •ta'Tiitii iiilcriially to thf furaniinu, iiliil 

! or fire pitiglia : tin- two lonli imilc on the coccyx 

npnr. <V)innniuic«tiii},' lininchcji iiri- fpvcn to the 

|i1 i-lric plcxii*-. 

^ , u-vd "II the front of the wwniiii, niiil 

with till- >ym]mtbctic ]>l>!\u>< (i|Nin tlie uurtu. It in 
mxl npon the two iutei'itat iliac arteries to furiu the 
, which arts placed on each vide of tlir Madiler a>»l 



I, then* an; upon the ncvtuvl hollow vim-i-m ploxiura 
iipalhvtir, ]uirb< of which aif vi^iMc in thn varioiia 
liKwiction, Thi-y ftr<- lirrivi'il froiri tin? pelvic plcxiiM-)', 
• ovtT tln< hhiiiclKw of nrtKriM Hiipplinl to the 
vini; corn.'Bi>iiiiiliu}{ tiaiueH. ^'^ 

Droua Miiaele (Kij;. I To, 20), if not Hiillicieiitly well , 
inorr fully eipoMil liy ilruwin;; the sacrul plexus out' 
■lie foramen. It arita from the front of the sucruni/ , 
H^ 2nd, 3ni, and 4th Micrul foniiiiinu, fmni the }{roovc!«_.' 
hcne fonimina, from the grf-jit nAcro-sciatic ligamrnt, ' 
gin of thf grvfll i««cri>»ciiitic fornnicn ; and lenvn* 
[h the great Wicto-sciatic foramen, having the gluteal 
' nerve at itj< upper, and the aciatic and piidic 
I at it* lower boiiler. It ia iiuertnl into the upjN-r 
at tiochanter of the femur, behind the iuM-rtionof the 
niu» and geniellt It* artinti i» to rotnt4' outwunU and 



' litem lu, 







THE MALE ORGANS. 



abduct the femur, irnrl it ia tupplUd by branches from the 
Bucnil ufives. 



The Kectl-m and Externai- OitaANS or Genebatiox is 
THE Male. 

[The liluddcr with tlie urethra atid the rectum hiiving 
renioveil as directeu, should be laid ou the table with the rcct« 
uiipcnnost, mid tliut viFCUB i<hciuld be tilled with cottuu-woul 
clcAued, aud its luusiuiar fibres txposed.J 

The Keotum (Fig. 164, i6). The arrungenient of the peritoneu 
upon the rectum has beeu already described (p. 304), and 
loiigiludiuul muscular libies will be now seen to differ from tha 
of the rest of the lut>;e ititesliiie, in l>eing spread all around it 
instead of being collected in three bands ; they iiiw, h' 
thickened in front and behind, the anterior fibres {prar 
being formed by the fusion of the omental and free taeniae of Uic 
i!olon. The internal or circular muscular fibres become thickened 
near the anu.s to form the inteniul sphincter mus<:le, as will be 
seen when the bowel is opened. The numerous arteries are derived 
from three sourees — tin? sujierior hemorrhoidal artery, from the 
inferior mesenteric, which bifurcates on reaching the rectum, iB 
two branches running to within three inches of the anus ; 
middle hiciuorrhoidal from the intenial iliac ; and tlie infe: 
hu'uiorrhoidal from the internal pudic. The veins temiiuate ab 
in the porfcd system ajid below in the internal iliac veins. 

The intestine being opened along its unattaclied border, the 
luuious membrane will Le seen to be mnixjth, except near the aiitl 
where it is thrown into longitudinal folds by the sphincter, lit 
also it fn-quently happens that hemorrhoids exist. Three oi tul 
ininsverse ridge.s of luucoui- membrane (valves or /u/(/< (<//foui(4i 
will lie found from three to six inches above the anus. Tliese 
arc etiaceable by distension, cxcejit one Jilieation, the fold of A'oJU- 
laufcli, which i.t permanent and involves the circular muscular tibn 
as well as the mucjjus membrane. This is of considenible surgiq 
imj)oi-tance, us it imjjects as a kind of ledge from the right side< 
the gut, about three inches above the anus ajid might be perforaU 
by the careless introduction of a bougie or rectal tube. 

Tlie muioup membrane abo\e the anus for hulf or three- tjuarte 
of an inch has the characters of skin, and is 8eparate<l from the I 
luucouM structure by a more or less well dcfuied line (Fig. I "J, 
which indicates the position uf the seytum that originally i 



THE UECrUM. 



S67 



betwem tlie blind Fxtrrmity of t]ic fn-tal gut and the aniil dimple in 

till- niti-^jnn:nt. It is intCTtvtiiig to reinenilwr thnt the atrui'tural 

fO khiiwe ittolf in jntLoIngir-al cluuti^cs, that on urdinary 

.-I lui I'pitheliotua ixxurx in lh«.< lowMt jiart ol the rectum, 

while the part above ia attacked by u nmliKnant ^ruwlL of different 
character and tendencies — a columnar epithelioma. Immediately 

Fi«. 171. 




abuv* thr Drptimi the rectal wall pi^mt'nti a iiiintber uf little 
t... .1...^ lUKuna tmilutinrfi) in which »har]i foreign bodies may 

cavity of the Ixiwr] ig ompulliited lietween the fold of 
iiacli and the upj>er ma];^in nf tlie internal sphincter, and 



Fie- 17!.— Inner nirfhce of lover end of re«tum (after LoKhka). 

'. WTiiti) line of Hilton, at junc- 
tion of internal unci external 



KMial portion of the niiu-uii« 
mrmtirane with Uiunii- wnii- 
Ivnarr*. 

Cirrulu niuKulnr fibrr«. 




Ix-twn-n knul and 
• la of the inuruut 

> citit, 
ilimne 

— 1 ^111. 



(ihincti'n. 
R. Inttmiil Mjihincter. _ 

V. Cutanroua tone abore ooal aper^ 
lupr. 
10. Ti'UilinMua Itbrm of loagitudiual 

miiH'uUr coat. 
12, Katrnial iiihincter. 



368 



TUK HALE OROANS. 



opporite the Bpliinct«r the wall preaeiits a nunilx-T of loiigituili: 
plicAtions called the roluuinm rtdi of Mtirgngni (5). The line uf 
junction between the two aphinctcrit ia indicated by a ir/iit> liti* 1 
in the mucous membrane (Hilton). 

[The rectum is now to Ins carefully diasecled from thi- lilndil 
which is to be niodenitely distended with iiir, and the uiidi-r mtf 
of the penis nnd bladder beinj< then plai'i'<l belore the stndeut, ha 
to dissect out thoroughly the whole of the purt« exiio^ed.] 

The Penis (Fig. 172) is seen to he conipOised of the two < 
cavernosa, forming its dorsnl segment, and the nieainl w 
tpvngioium. urethra- (21), situated between them ventrally. 
latter is prolonge<l in front to form the ijlam yniit (20), wl 
behind it terminates in the dilated part called the biilh (18), wb 
is covered by the bulbo-cavemosus muselc and should be cle 
liehind the bulb is the slender nn-ml/ranoiit portion (15) of 
urethra, and the proetntf (13), the posterior surface of wbicLJ 
now exposed with the resinilir xnninnlet (10), w«t defrrrntia, i 
base of the bladder. On each side of the membranous jK'rtion 1 
the urethra may be found, by careful difisection, a little yelli 
b'xly of the size of a pea, Cov^ptr't ijlaiul (Fig. 1 73, 11), the du<'t | 
which opens into the bulbous portion of the urethra. Ity lunij 
the preparation over, the dorsal a.spect of the penis will Im- bruii{j 
into view, and tiie dorsal vassels and nerves will Ix; seen, 
dorsal vein may now be traced to its junction with the plexus 
* veins around the prostate and neck of the bladder. 

The Prostate (Fig. 175, 14) i» shaped like a chestnut, luTil{| 
the small eml or iipex downwanls and the base at the ' neck ' of 1 
bladder. Its weight in the adult is about six drums, the same 1 
that of tlie testicle ; its length from base to Hfiex is in he 
from 1 ^ to 1 i inch, and the greatest transverse diameter is 1 
13 inch, but these measurements undergo great variati(ju iu 
persons, the subjects of ' enlarged prostate,' The prostate pre«e 
two indistinct lateral lobes, llie division l)etween which is markq 
by a slight groove on the posterior surface, and an occasio 
pr<jjection in the floor of the urethni is de.scril>ed by ton 
authors as a third or middle lobe, but is the result of morl>i 
chntigc* in that )iortion of the body which lies above the pn 
static ftssmx' and in front of the ejaculutory ducts. The jirotla 
fttiure (12) is a little cleft iu the centre of the iKtsterior oopvCJ 
or base, which transmits the common cjaculatory ducts and siiiit 
pocuhiria. The ttrutture of the prostate is partly glaudulor 
partly muscular. A powerful sphincter of unslriped mn 



370 



THE MALE ORGANS. 



partly Btrijied (near the apex) and partly unstripetl, serves to et 
the prostatic secretion into the urethra and aid in ejiieulnting 
mixed seminal and prostatic fluids. The glandular atnicturtj 
situated mainly in the ]>osterior and lateral portions n( the btif 
beloM- the openings uf the ejnculatory ducts, and consists of btSDcl^ 
follicles, which secrete a kind of mucus, and are sotnetimes ihi" i 
of concretions. The relations of the prostate have been given j 
p. 3ft3. 

The Vesiculsa Seminales (Fig. 164, 14) ore tlescrihed 
p. 354. Each vesicle consis-ts of a convoluted tube, uarrowint; 
the base of the prostate, and joining the corresponding «m ifc/Vi 
to form the common ejticidntorj/ duct, which will be ofterwuids 1 
opening into the urethra, 

The Bladder (Fig. 172). — The jieritoneal coat of the blailder I 
been already dissected and the relations of the viscus have 
described (p. 352). 

The intucular coal consists of three layers, external, middle, 1 
internal. 

The external layer, sometimes known lis the ddrv$or 
consists chieHy of longitudinal libres which are best set-n on 
anterior and posterior surfaces of the vi.scus. Those jiluced in I 
pass in the anterior true ligunientx, and are attached to the i« 
surface of the pubic bones and fvniphy.^is {vesko ptilru- my 
The posterior libres join the ]«.>8terior j«irt of the prostate. 

The mulJU layer consists of plc.xiform and circular tibrort, whid 
form the njilanctfr vcgicce around the neck of the bladder, anil 1 
closely connected with the prostatic sphincter. They decosaate | 
their distribution over the greater jjart of the bladder. 

The internal layer is longititdiuiil and ple-xiform : it is continn 
with the longitudinal fibi-es of the urethro, and is joinctl In- 
fibres of the ureters, which meet in the middle line and are spn 
over the trigonum (Ellis). 

Beneath the uniscukr coat is a quantity of louse subniuci 
connective tissue. 

[The bladder is to l)e opened along its anterior inferior wall h] 
kuigitiKlinal cut, which is to be continued with a strong juiir 1 
scissors llii-ough the uiiper surface of the pr:).<tate and the whfl 
leu<'th uf tile urethra, m the lutter portion being a little to uuei'' 
of tlie middle line.] 

Interior of Bladder and Urethra (Fig. 173).— The nmci 
uiembriuie of the bladder, if healthy, will be [mle, and is more o« 
)ess plicated throughout, exce\i\, neixv the vuethra, at the trianguliaj 



THE rRETHRA. 



371 



I Irigonum vaica (t ). The tlircv Milu* of this triungle 



Ian inch Iimg, and the ihn-e nngli.- 



1(1 to the 



1 coiTfjipond 
ureters ftlM>ve, ami tlir inti-rnal iiriiinry ineatn* 
horizontal rid^ nf mucnuii nu'iiibiiiiir Htt<.-n<lit between 
it*n., and fnjni the middle of th)» nnm ii vertic.il fold, 
mVir, at fur iu< the inleniul upeuiu^ of the urethra. 1/ 
■•An one of the ureten*, it will hv ueen to pan 
the couta uf the hliuliler, tind tun •oinL-times 
ogfa the wuU uf tltc rectum when the linger ia introduced 

■^ (F)g- I '-) '* n1>out »ix And n hnlf inrhcs in length 
^m are at i\«t, hut when tlie peni« ia Htrut<-)ied during 
^1 after tli« reinuval of the ]iart» fruin the IxMly, the 
^wed to eight inchit» or ovrn in<ire. It is tlivided into 
ic, nienilirnnoiu, Inilhoug, nnd spongy |>otti<in8, and the 

Kde, jire*ent* thnf iltlntntunn, one in the prooUttic 
the liull)oui« jiortion, and om- in the nnterior part of 
tinu (fowui imvicularix) ; iind thri't nnnJrifliiiiiii, one 
ity (intenml und externul nieatUH), and one at the 
t fKirtiou. The external ineatun is t)ie leant dtlatatuhle 
entire puMoge. 

ttatu portion (Fig. 173) piercing the prostate, iii nearly 
IlKction, uml lirfi wmicwhat nean-r the pubic than the 
Kof the gland. On section, nenr it« middle, it is seen 
^na]>«i| like a {J, with tlie curve directwl towards the 
It ia alxiut an inch and a ([uurter long, and wider in 
111 above and below. At the po«ti'riur wall is au 
Jeil the ivrii nmntanuvt or eapiil yiilUinnjinu (6), 
iinal into two hollows (reprc*e:ited by the free 
[the U on section) called the jtrottiitic liinum ^8), 
pmatatic duct^ 0|><tn. On the vera montjinum will 
oriflce of ilm «'iiM» fiiiciijtii^ (5), a little blind 
Ibaekwards ; lUid on each side near lt4 niiirgiii o)k.'u 
atory duet«.* The unterior wall showss the ii]iertureii 
I simple follicles. 

teanom jjoiiion (9) is the shorie«t and narrowest division 
Hand being placeil between the two layers of the tri- 
BKnt which meet below, it« upper or anterior wall 



inn nf the riniis pwulari* i* piven diftirtnitly by rnriini* iiiilhon ; 
nj' aod \V il»on pliiii' it oil (lie anterior, «nil L'nivdilhior ami Ellis 

•rt nf the vrni niontuniun. The disiTupnnry uruea from 

I tlur thnpr ami rdeiit of llir ridf.'e. 



D n -2 



372 



THE MALE ORGANS. 



is Boiuewhttl longer than iU posterior wall or floor, the 
mcusuring about J inch and the latter A inch. It is enclosed 1 



Kii. 173. 




Fig. 173.— The bulbous, Dicmbnmous and prostatic nirthni, with pan of llw 

bladder, laid open from ubove (nmditieJ from Wilson). 



1 . Trigonum niiiciB. 

2. Opening of uretiT. 

3. Uvula %'c«icip, indiuiting the apex 

of the triL'oni'. 

4. Ventral wall of proetalc laid open. 
6. Opening of sinus poeiilHris. fho 

oritice« of the ejueulutory ducts 
He one on either side of tliis. 

Vi I Mim. 

M mne. 

I'l, IIS and openings of 

pnwtalic ducts. 



6. 



8. 



0. Mrnibninous part of the unlbn. ^ 
10. CruB poiiiii (cut). 
U. t'OH-per's gland and lomnwaa 
luent of ila duet. 
Upper 4urfiK*e of the hulb. 
ComineiReinent o( bulbous porlJoB 
of uretbnt. 

14. Se< tiou of erus ponis. 

15. EnlrnncB of duct of Coirpo'i 

Kland. 
Iti. SiHiiigy part of the urcthn. 



12. 
13. 



uua. I 



COBPOBA CAVERNOSA PENIH. 



373 



ipliincler of circular involuntary fibres coiitiiiuniis with the circiiW 

\ft^ uf the blailder and prostate, and is Invtsttil l)y tlrp fllireu of 

I dc«p traiuversng periniei muscle. The tiuicoua nieuibntne is 

ith, and preaenta no orifices ; it is frec^ueiitly stained of n red 

huUiouM pnrtum ttj},t\u.- part com-spunding to the bull) 
nally, in about an inch lonj,', but there ia no line of 
ation between it and the spongy portion. The canal is 
at this »{>ot, and in its Hour are the two minute orifitea of 
tductii of Cowpcr's glands (15), whiih run oblifiuely through the 
1 of the urethra for some distance. The bulb will be seen to 
I continuous with the lorjaiK spoiigio-suni, which surrounds the 
y or anterior {>ortiou of the urelhni, and exptinds again to form 
mpenit. 

Sponijy jHtrlum (16) is the longest part of the cuniii. It." 

bte is somewhat smaller than that of the bulbous portion, bnt 

in the glans ]>eni.i to form the /'wni tuivieiitaru, again 

aantnicted at the infalut or oriiice, the lea.'st dilatable 

of the urethra. Along the Hoor of thi' spongy jwrtion are 

herons mucous follicles or lantniE, the oritices of which are 

sled Ujwanls the meatus ; a few similar follicles are situated on 

ipper surface of the urethra, one of vvhirh, opjuisite the fossa 

ricularis, is called the lacuna viaijna. Thi.s can seldom lie made 

t when the urethra is ojicncd from aliove, 11s here directed. 

' mucous membrane is smooth and |iale in heahh, but iL^sumes 
tchamcten of skin in the last eighth of an inch of its length. 
i rtiident should notice carefully any traces of stricture, which 
I pruluibly be found, if present, in the bulbous jwrtion. 
Beneath the raucous inend)rane of the urethra thert' is a thin 
of erectile tissue, and outride this a tunic of longitudinal 
nrolimtary muscular fibre, continuous with the submucous layer of 
I blailder muscle (Ellis), and intermixed with tibnnis tissue, 
he Corpora Cavernosa Penis may now be seen as two va.sculnr 
■ enclosed in fibrvnis sheaths, which unite to form on imperfect 
septum between them, known a.'* the KpUim jxctinifuniie. 
172, 19, Fig. 174, 5) from its comb-like appearance. The 
sheath or tuviai Hibvijinra consists of two layers of fibre.'-, 
nil longitudinal and internal circular. It is the latter that 
1 the septum, and from itj< inner surface triiheriiltn or Ihread- 
proce8»«8 are liistributed through the vascular tissue of the 
The attachnienUi of tlie corpora cnveniosa, liy iWu ctvixw, 
uvliiu-puljic rami hare been Been in the tlvissetUoti. lA V\\t 
fum. 




374 



THE MALE ORGANS. 



A transveree section of tlie b<xly of tlie penis (Fij;- I"-*) ' 
the reticu]flt«il structure of the corpora envernosa, ami that of tit« 
coqjuB spungioiiuiii, around the urethra. The dorwil vein (l 
with a donwl arterj' (2) and nerve (3) on each aide of it, lien ato 
the upper surface of the corpora cAVernosa. The artery of 
corpus cavernoguni (4) is in the suljstancc of the corpus cavemo 
A transverse eection through tlie posterior part of the gk 



Fig. 174. 



Fir. 175. 





presents a diffeient asi*ect. It shows the anterior extreDiities of 
the corpora cavernosa, now separated from each other, aunouudeil 
by the coarse erectile tissue of ihe corjtus spongiosum, the whole 
being inve#tc<l liy tlie int<'}5uinent of the glans. On lei.-tioD, th* 
urethra in the jirosUile has the \J form already de*cribeil, in th<? 
membranous |x>rtion it is stellate, in the body of the peni* 11 



Fig. ITi.^Tnnefersc' section of the penis (from Vr'ilMiii). 



Dorsal vein. 

Dor«U artery. 

Doraal nerve. 

Artery of corpus cavemotum. 



5. Si'ptum pertinifiirme. 

6, Urethra, ^urruiiiuted by 

spoo^ovuiu. 



Fig. 176. — ^Tranfversc trction of the teatide (from WiUon). 



1 . Tavity of the tuni™ Tugiualit. 

2. Tunica albupncu. 

3. Mediuitinum trstU eiring off 

numerous K'pta. 1 lie cut ex- 
tremities of the vraselfi below 
the fijture heliiii)^ to the rete 
tejftis; ufiii tli»M* above to the 
arteries and veius of the ovgun. 



4. Tunica va^eulona, or pin maUr 
testiK. 

.5. tine of the lobule*. i'on<i<tinr ( 
the oorivolutionip of thi' InV 
•K-ininiferi, and trrminiitinf I 
a aiugle duct, the vaa rKtum.| 

6. Section of the epididymif. 




Fig. 176. 



THE TESTICLE. 

the fnnn of a IiorizontuI fissure, in the glana the tiHSUTc 
n.Wrtiail, and alxjut the neck it lias tlie transitional shape of an 

m^^ T- 

^^^e Testicle (Fig. 175) han already been seen in its position 
R the »cn)tura, and its structure should 
he investigated as far as possible, 
lie testis consists of two parts, an anterior 
»rg*r portion, the liody ; and an accessory 
the ejiidulymu, which lies on the outer 
of the pasterior border of the IwKly, itml 
Icontinuous below with the vas df/ereiiD or 

The testicle has three tunics. The timiai 

IniUu (i) is a serous covering derived 

Ijr from the peritoneum, and may be 

as consisting of two jiortions, the 

'nalit propria, which is adherent to 

Mf organ, and the tuvieu i-aginalU rfjUxa 
liiung the scrotal sac. The liatica vaijinalu 
invests both eidvs of the body of the 
111, the outer side of the middle and nearly 
*h«le of the upper porlioii (j,doliua nmjor) 
lihe epididymis, and the lower half inch 
e epemuitic cord. It is deeply inflected 
ten the midiUe of the epididymis and 
of the testicle on the outer side, there forming a deep pouch, 
•a the ilu)itnl funM, by which the external aspect* of the 
luity be rtcognised. The Imiira aihtujiiita (2) is a strong 
w cafwule enclosing the body of the testis, and sending into it 
l«hinil a vertical process called the media*! inmn (3) or corpus 
iiuorianum. From this, secundarj' proces-ses or eeyla radiate 
le inner surface of the tunica ulbugineu and sejmrate the lobtdes 
the testicle. The tunica albuginea is inseparably connected 
*>lh the tunica vaglimtis propria. The tunica x\i»cti!osa (4), beneath 
•K tunica iilbuginea, is a delicate membrane containing the 




( 



Fig. 176.— .\n«toiny of the testis (from Wilson). 

are rcprewntcd in thi» diapiun. 
7. Coni viisculrwi, mnstitutiiig the 

kIoIiuk major cpidiilyniia. 
9. B(mJv' of tlie t'pltUdvnus. 
.''. Infill!! minor cp'u\l<\ym\». 

10. V(m ilefiTcnsi. 

1 1 . Vtts aberruns. 



1> li Tunica albuxinea. 

%!■ HidiMtinum tc»tii. 

d Libuli tf'stis coin]>oted of tubuli 

•em mi fori. 
t i. VoM nsUu 
*. Brtr Irrtit. 
' la eHbrvntia, of whieb six only 



i 



376 



PELVIC VISCERA OF FEMALE. 



ramifications of the blood-vesaela, but thesv cannot be seen i 
when finely injected. 

The Epididymis (Fig. 17C) is divided into tliree i 
upper extremity w the html or ijUihut viajm- (7), which 
into a number of com' vasculoti ; the central portion L» the Wy \i 
and tlic lower e-xtremity the tail or ylnbm minor (9), which is Urij 
than the body, and often as large as the licad. From this uu 
the vas dtferent (10) or duct of the te.slicle, and clone to its poii 
of origin may be found a minute blind tube of variable lea 
extending along the cord and called the ctu alxrrranii (11). 

On making a section of the uninjecte<l testix, little more cut 
seen than a ma-ss of a clrub colour, which may be dmwn out 
threads ; these being the minute seminal tu))es. In on inject! 
preparation the tube* may W traced a» follows (Fig. 17fi) : — 

Each lobule if composed of convoluted tubnli teminiferi (3 
which anastomofie with one another : these as they enietg« IkA 
the lobules become straight, and form the rata recta (4^, »b 
twenty in number. Entering the niediusliiium, the vosu 
anastomose to form the rett tmtu (5), from which arise the 
effernitia (6) ; and these, from twelve to fifteen in numWr, pie 
the tunica albiiginea to form the eoni nueuloti (7) of the gloh 
major of the epididymis. The ducts are then all collected into 1 
tube, which by its convolutions forms the bo<ly and globus miu 
of the epididymis, and ends in the vas deferens. The latt«T enU 
the abdomen through the inguinal cunul, and lin:r been traced to 
opening, u])on the mai-gin of the sinus pocularia of the prostate. 

Attached to the to]) of tlie testis, immediately in fnmt of 
globus major of the <-|iiJidyiiii», may generally be foun<l one 
two little vesicles culled the hydulidK of Muryiurni, the remains 1 
MtiUet-'s duct ; and in the cellular tissue of the conl. imnieiili:it«li 
above the epididymie and Ix'neath the funicular timicu va 
is seen a i-mall white branching structure, the Orijan of Oimlik^ 
which is probably part of the remains of the Wolltian bo<Ijr of tlw 
fcetus. 



Pelvic Viscera in the Female. 

[Tlie organs removed from the pelvis arc to be laid out upon lln' 
table with the rcetmii tiiiwiirds ; this is to be cleaned, and, after It 
has been examined, is to be dissected from the uterus.] 

The Beotum (Fig. 1 78, 4) corresponds to that of the malq 
but U related anteriorly to the pouch of Uouglas and ragiit 



TUK VAamjL 



•ATI 



be bloddfir and rccto-vemc*! {loucli. Th« (loftcription 
^will be fotuid at \inijtfi 3A4. 

ktiun UdiiH reverMKi, llxi" Idmldrr mul iiri'lhm iiro next 
ami examined. Tlic iwiii'Miviim i» to !« diiwcctnl 
Kldw and left attached to the ntorits. j 



7)' 



iiler trntinvi'i 



id: 



niirrower in 
ittiicbcd 

t the uock f>f thu iit*'ru>i and In tlie front wall of tlio 
he ivlatiuu to ttiv Vi-Kicoliu nfuiiiiiiU-> and vuxa diTi'nMUia 
eounr wanting. The urtiem turn forwanJM on each f\Ar 
pi>r jiart nf t}it> Viigina to gain thv luw uf ttie bladder, 
ibliqiirly for a iihort diatunrr in the vtsico-vaKiual wiptuni, 
aida, pjeri'injj the coat" of th« vinciw to open by two oriliffca 
incii apart, a» in the niale. The Htrii>.'tur«> of the bladiler 
male t.'orTei<}Minda to that of the mule (nee l>»;{e 37(>). 
retbra (Fig. 178, j j) of the female is u Dimple tube about 
lid a half long, and runn downwards and iili};litly forwarda 
I tite vagina, piercing the triangular ligitnientM and deep 
U petiiutii mu8cli> to open into the vestibule. Anutomi- 
mu nponJi* to the iiruMtatie and mi'mbranouii [Mirtiona of 
^■bra, but morphologically it in aaid to ri'premmt only 
^Bf the prustatie urethra which lien above the oiiflceit of 
^^h dacta. It vt capable of xiiHicient dilatation to admit 
^DT exploration of the blulder, but the reniataiicu ia 
iJe at tlie oxtrnial niMtUH. The mnoou» and wuncular 
rular and longitudinal) resemble llioMe of the mcmbranou:« 
I the male, and the ujiper part of the tube in inve«ted by 
mu»cular librea which ]irubably correitpoud to thow of the 
B Utr male. 

^Her and urethra are tu l>« carefully removed, and the 
^BttTUit ej,po(U'd. Th« broad ligament of the utenm 
^Kined out for the examination of the Kidlopinn tube 
^Kgamrnt, an<l the preparutir<n must ulterwuitU bo 
^H the direction of the ovary, which ia placeil ]m»- 

,(Kig. 17S, 14) huabeen seen in its j)o»itioiiin thepelviu 

; i* conipo»ed of longitudinal miHcular libn.'S enclosing 

, and lined by a mucoiia membrane, which, when the 

will be »«en to form tmnsveise rmjm, starting from 

Itidgei), the colimiitm riujiiniiu, on the anterior and 

hi) miUTior wall is about 3^ iucliea \utig, V\vq 



378 



PELVIC VISCEKA OF FEMALE. 



Fig. 177. 




posterior wall an inch more. In iu ordinary conilition it I 
tissHR', sliaped in cross section like the letter J-j witli n long tr 
verse and short lateral limbs, and runs upwanls and bntkwi 
in tt slightly curved course which dii 
acconling to the degree of di«t*B 
the rectuiu. The lower end of thdl 
will be felt projecting into it« citvity, ' 
the point of reflection of the muc 
membrane on to tlie os uteri (fornix],] 
much higher behind tlian in froiit, 
hence the greoter length of the po»teri 
wall, which Lie* in contact with both 1^ 
iif the OS. At its lower end are 
remains of the hymen (caruncula jnyrtv" 
fonatt), mid below these luay be seen th« 
orifices of the two small ijlundt of Bt 
tlioliu, above two fohU of vulvar luuco 
meiubrane called the nymjih(r. 

The Uterua (Fig. 179, i) i* 
or le«8 pyriform in sliapo ; the npj 
part or body being broad and 
what llutteneil from before backwanU, t 
larger above than below, the lower 
or rcii'u: being cylindricaL It opens Wo 
into the vagina. 

[The anterior wall is to lie dividt 
vertically with scissors, and the cut pp 
longetl on each side towards the Fallopii 
tube.] 

The direction of the long axis of the uterus is doubtful, but 
all pmbaliility it varies considerably with the changing conditio 
of the bladder and intestines. Under ordinary circuinstances 
summit never rises above the plane of the pelvic inlet. 

It is about three inches long, and its maximum transveua 
antero-posteriur diameters are two inches and one inch respective^ 
Its unteiiiir surface is liattene<l, and is covere<l with jieiitoneum a* i 
as tlie jinntioii of body and cervix ; its posterior surface is convc 
and is invested by iieritoneum over its whole length as far a« 
attachment of the vagina. Its narrow lateral liorders give at) 



iHi 



Fig. 177. — Longitudiiiul section of uterus unil upper part of vnflna. 
II, Anlcrinr, p, roaterior vagiunl wall. 



THK UTEKUS. 
Fif 178. 



379 




1. 8r-:- '■■-•- 

2. 1' 

3. ri-tit-iUiuui. 
I. Bwtiim. 

■ ' 1 ^11. 



Fig. ITS. — Section of fenialo prlvii (ufter Henlo). 
14. ViiKinii. 



la tixi uiiiilow). 



! liladdrr. 

' il 10ll«'t«. 

r 0* uteri. 
' at atrrL 



\'i. I).i|i trninvemn pcnniw. 

10. Kxl'Ttiitl upluiirler ani. 

17. Ijiliiuiii nmjii>. 

IK. Inlpriiiil apliiiictrr ani. 

19. UnatllptMl miim-nliir Hhre. 

20. .\niiii. 

21. I'rrOirn 

Tl. Ill ' tfr am. 

2:1. I. 

2-1. 1' • ii'l «[iliincter. 

2.5. I'n>trip<.-<1 muMuUr fibra. 

■Jti. \'c«iclii. 

U7, Vagiual oriiiw. 



380 



PELVIC VISCEllA OF FKMALK. 



luent to the broad and utero-sacrBl ligaments, and from its ewp 
angles run the oviducts, the ligaments of the oviiry, and tin; rou 
ligaments. The cerrical j/ortifm may be divideil iiito three O'lie*, sn 
upper, supraviiginal ; a middle, corresponding to the area ul vagu 
attachmeut (which Ls higher posteriorly) ; and a lower intrtva^'ia 
segment, the " on uteri." The relative dimensions of body and n« 
ditfer at ditfereAt periods of life. In the child the cervix i» 
longer, in the virj,'in the two ports are about eijual, bat 
parturition the body is left nearly twice aa li.mg aw tlie cervii. 

Fig. 179. 




The eaviiy 0/ tht body is triangulai' in shape, with the sp«i 
downwards nt the os internum, and the e.xtreniities of the Iw 
corresponding to the orifices of the oviducts or Fullopiim lidt 
It is lined by a smooth mucous membrane, on the jtirl'iice of wlii< 
oi^en numerous tubulnr glands, and it has ciliated epithelium. 

The cavity of the cerrit is fusiform. It opens into the caiHty ( 
the body by the os internum and into the vagina by the lu wifl-nu 

Immediately within the os uteri, on the pa«terior aspect of 
cervix, is seen n vertical ridge with oblique ridf^es ratliatini; /« 



Fig. 179. — DiBgram of Uterut with its appendiges viewed from the front (I 
Wil«)n). 

1 . Body of the uterus. 

2. Funduu. 

3. Cervis. 

4. Os uteri. 

b, X'ueinn. 11 

6, 6. 5roBil lijcuiBpnt of the ul«Tiis. 12 

7- Coiivi'xitv of the lirosil li^inciit 

formrJ by the ovnry. 

8, 8. liuund UgniiicnU ol' the uterus. 

9, 9. Fullopian tubes. 
10, 10. Fimbriated extremities of Oic 



Fnllopiiin tube*, on the 
side tlu' iiMJiiTh of the tuh« | 
turneil furwurd* in order to* 
it* nttium aMomiiutlf. 

11. Ovary. 

12. Utrni-ovariiin ligiunetit. 
l.S. Tubo-nviirimi li^nniviit. 
14. rpritotit'ura of uiiteriur surfwej^ 

uterus, contiuiioui* with 
unterior layer of the braid J 

TO«\V. 




THE KOUND LIGAMENT. 381 

it, pradadng th« Appeanutee known as tlic arior vita uterina. A 
umilar appearance in the mucous inenilirani' of the anterior surface 
oC the cervix has been necesurily diMtroytMl by the incision. These 
markings correspond to muscular fiutciculi, ami are hence of a 
diffeient nature from those in tlie v»xina. 

The tUrro-taend ligauuHtt arc two flat banilx uf smooth muncular 
fibre, which run from the sides of the uterus iMickwanls in the 
uteto-rectal peritoneal folds (which form the lateral boundaries of 
the pouch of Dou(;IaH), on either side of thu rei-tum, tn the front of 
the sacrum near the socro-ilioc syuchondniM-s. 

The uterus is composed of pale unstriiiud iiiusouliir fibiv together 
with a larfft quantity of areolar tissue. In ]ir(^;;niiiK-y the nius- 
cnlar fibres become much devcIo])eil, ami art; ilivisiblt! into three 
layers : an external, chiefly transverse in direction ; a middle, 
irregular ; and an internal layer, fonuin^; s]iliinL-t«!rs around the 
tubal oriflces aii<l cervix. 

The uUriw. artrrg, a branch of the internal iliac, enters the root of 
the brood li){ament to reach the or^an at tlu; level of the cervix : 
crossing in front uf the ureter, it thifu runs ufiwards in a serpentine 
course alonx the side of the uterus, giving' branches to liotli walls 
and to the upix;r part of the v:^;ina, and at the ii|i)ier ati<{1e of the 
uterus it anastomoses with tlie ovarian and funicular arteries. The 
tifrnW rriiu form a plexus with the. ovarian and terminate in the 
internal iliac veins. The mijinnl aiiirim come from the internal 
iliac and vesical, oiiustomosinK above with the uterine and Iwlow 
with vestibular twigs of the external pudic 

The nrirai of the uterus arc ih-rived from the liyi>o^'iistric ])lexuR 
of the sympathetic, the spermatic plexus, and the :)nl and 4th sacral 
nerves. Ur. Koliert Lee descrilied numerous (;an<{lia on the surface of 
the organ, and lielieved that the nerves eiilar;;u durin<; ]ire;rnancy. 

The Fallopian Tubes (Fig. 17$), 9), are found at the u])pcr 
part of the broad ligament, one on each side of the uterus, to the 
angles of which they are attached. Kach tube is about four inches 
long, and of very small calibre at the utenis, but ){radually exjiands 
to form on ampitUa and terminates in a trum]H.-t-slia)NMi exj^msion 
fomisbed with a number of mar^'inal processes {fimWni\ which 
radiate from the external openings of the canal. One of the 
fimbria! {fimbria otariea or tulnntrnrinH liiiniiniit, \t,< is iittai:hed to 
the ovary, and serves to ilirect the ostium in gnispin;; the ovum a» 
it emerges from that oigan. The tuls- is muscular in structure, 
and is lined by a longitudinally ]ilicated mucous membrane! with 
ciliated epithelium. Its external oriKce {imtiuia aMumiiMk) opens 
into the peritoneal cavilty. 



382 



PELVIC VJSCEBA OF FEMAI-E. 



The Round Ligament (Fig. 179, 8) pliici'il in tlie 
part of the broad ligunicnt is cuniposetl of iinstripeil uiiiwnlar I 
and areolar tissue, and is covered by peritoneum. It exlemU I 
the angle of the uterus to the inguinal canal tlirougli wliieli if 
tu become lost in the fat of the labium. In the child and nt 
aionally in the adult it is acctiinpunied for a short distance into 
inguinal canal by a funicular process of peritoneum called the nnwf 
of Nude. 

It is supplied by a small artery which anostomoiics at 
superior angle of the uterus with the ovarian and uterine, 
lymphatics open into the inguinal glands. 

The Ovary (Fig. 179, ii) is an almond-shaped body |>ri>jecti 
from the posterior part of the broad ligament and utturlicd in 
superior angle of the uterus by a muscular band, the ulero^ntrid 
ligament (l2), and by its opposite extremitj- to the Jimbria i/vnrinxi 
the Fallopian tube. It rests in a shallow jx'ritoneal »ulcu.« :/o{ 
otariea) at the side of the true pelvis, lietween the internal i|j| 
Urtery and vein, a little below a point midway Iwtweeu thr anter 
'superior iliac spine and the median line. It jireseiits for de«criptioa 
free and an attached border ; two extremities, the uterine and tnh 
and two surfaces. Its true position is doubtful. It is gcnen 
re])resented as lying horizontally with its surfaces looking npwa 
and downwards, and its extremities pointing inwards and outwar 
but there is reason to believe that its long axis is vertical, 
surfaces looking inwards and outwanls (Symington). 

It is composed of u libro-niuscular stroma condensed periphcr 
info a cortex {lunUa atbuginen), which is covered with epithrliun 
and contains innumeiuble ovistics or flraajian veniclfji. I'rnni tin 
to time certain of these ovisacs eidarge, approach tl>e surface 
burst, discharging each an ovum, which is received by the mou 
of the oviduct and conveyed to the uterus. This jirocess causes | 
scarring of llie originally smooth tunica albuginca, and certain chan(j 
in the ruptured ovisac which lead to the formation of ayellowinhma 
called the atrpiu luteum. Should impregnation occur, the iuorea 
determination of Wood to the ovary gives a much larger developwe 
to the coq)Us luteuni than under ordinarj- cireumstances, and lienfl 
we hear of a " corpiis luteum of pregnancy " in medico-legal iuve»ti 
gallons. 

The broad ligaments are duplications of peritoneum extendi) 
from the lateral borders of the uterus to the sides of the true jielv 
and present each an anterior and a j>osterior surface, a smooth or fn 
bor<ler, an intenial or uterine bonier, an external or obtunitor bonia 
attached to the obturator fascia, and itt\ mfcnox liorder or ba«, ii»>l 



UOAMKNTS OP TOE PELVIS. 



383 



■ to Ut« Irvator wti. Bctwern thu Iwu luininiG arv the foUon- 
innM : — (1) The oviduct at tho sujKfrior Umlor. (2) 
iJVar.f uu<l it» liKHiiieut, jirojeilinK fiom tho iMwtorior (tiirfiu-i:. 
(3) The roitud liiramciil, ptxytfcliuj; I'ruui tln< ttiityri'>r »iirf:i<f. 
(4.1 T( .'ipliorun, or orx«u of Kmu'iiuiUllvr, n-lic* 

of ihi- lUivr thi! ntlJichwl bonlor of tlu- ovarv. 

(5) liUiiU <ji (I liar ttljti! i iiti-ni-pi-lvic' li^nimeul'i), 

(6) Cohnecttvi- miiii with tlic itnt)|K-ritiiiU'ul ti&«uc. 

(7) Tb* iitrriiic. (i>';inaii mul fuiiii-iilAr vf».i"l>., all mei^ting at the 
tiorkoglc of ilie uifiiii. I ^) Thf iitcrinn ami ovarian nervrA 



LiUAMKNTH ur THK l't:l.V18. 

he remainint; «oft liiMUes ure to be ri'iiii>v«l fintti tlie halve* of 
Ihe pelvi«4 alid tlie wveral li^uivnts to be iliiMn-ctvl muI.] 

Artioulation of th« Vertebral Column with the Fel7iB 

~ - — Thr la*t liiiuJiar verlfbrii is loiinwtoJ witli tin' Murruui 

..'.latinn of the •■tviTuI li^TUiu-nta coiriiiion to the vertebral 

colitiuui uD(l by an iDt«r\'ertebral auUitancc, which, like the laat 

Fi(t. 180. 




Tig. 180.— Ligamnit* of the pelvis {tiom Suppey), 

4. i. Antt'ilor .-turnt-iliitr ligiimont. 

5. .5. (jiTttl »n<Tn-atiutU' liKumiiut, 

6. Smull fucrtiMrtutir liguiiitTnt. 
:eat 7. Kibro-curliluge of tymiiliysU. 



U>»vr part o( uitrriar common 

l,^unMiiiI nf ^.-i If line. 



38i 



LIGAMENTS OF THE PELVIS. 



lumliar vertebra, is of much greater thickness iu front than brhin 
Tliere are also two special ligniuents, the sacro-lurabftr and ilii 
lumbar. 

Thu lacTO-lmHlxtT ligamaU (3) is short, thick, und tria]i;fu]iir ; tod 
is attached to the transverse, process of the last lumbar verteb 
above, and the ujiper border of the sacrum below. 

The iliit-tuwliar ligamrnt (2) is triangular, and pases horizontilt 
from the tip of the transverse process of the last lumbar verttlit 
to iIr- cn'st of the ilium chwe above the sacro-iliac articulation. 

Bacro-iliac Articulation.^ — The anterior taaro-Uinc U>/ 
(Fii;. 180, 4) consists of short fibres passing between llie anter 
surfaces of the two bones. 

The jtofttridr aacro-iluic lit/ameni (Fig. 181, t) is composed 
strong ligftmentous bands, connecting the rough jxjrtion of 
ilium behind the auricular surface of articulation with the i>o<itena 
surface of the siicrum external to the posterior foramina. 
o6/iVyi(r mcro-iluic lujament (3), is merely a superficial portion of ih 
posterior ligament, whiih reaches from the posterior sujwrinr spin 
of the ilium to the third lateral tubercle on the sacrum. 

When the ilium oud sacrum arc separated after the dissection 
the other lii^mueiits uf the jKjlvis, a ili^tinct layer of cartilofie »i 
be fomiil between the two lioiies, >vith occasionally an intervtaiis 
space. The Joint belongs to the ' amphiartbroses,' and is onlj 
susceptible of very sli||;ht motion except under certain iiuthulcgia 
conditions, .-•uch as ankylosis of the hip, 

Sacro-eoiatio Iiigamenta (l^ig. I Hi). — These liganienls li«« 
been iMirtially exposed iu the dissection of the gluteal rvgion. 

Tlie (Sreal Mino-ffifitif lujamevt (2) is broad at \\a \ipper utttd 
ment to the posterior inferior spine of the ilium and to the side 
the sacrum and cix'cyx, and after narrowing consideralily exfund 
again t-o become attached to the inner and back jmrt of 
tulierosity of the ischium. A portion of this ligninent, by 
falciform prolongation to the minus of the ischium, hna V>een see 
to protect the pudic vej<sels and nerve : its ischial extremitr 
continuous with tlu- tendons of the liiceps and seud-tendinokU*, 1 
is occasionally separated from the tuberfisity by u bursa. 

The f^niall tnrro-Dcintic ligammt (4, 5) is a strong triangtilar 1 
attached by its base to the side of the sacrum and coccyx clnae I 
but in front of, the great ligument, and by its apex to the apine ( 
the ischium. It sejiarat^s the greater from the lesser sacro«ci<t]V 
foramen, and is closely incorporated anteriorly with the coccygwa 
muscle. 

Articulation of the Sacrum and Coccyx. — The anU 



THE KYMPtlYStS PUHIS. 



ZH5 



mcni-eoeefftat Uyitmmt it a lliin ra«.'tculiiii, paHsing from the OHtcrior 
of llie aacnuu to Uie fruul uf the coccyx. 
^ .^u fKitterior mcro-eoccyyeal lujanunU ia uttncheil to the lower 
cipeiiin^ of Uir Mienl canal, anil ptwaeii along the whole length of 
th« p<ict«rinr Aurfaco of tho CH-cyx. 

A Htiuill in/TwiWu-it/iir rarlUii^ intvrvvnca between the Micrunt 
and coccyx ; and the cijniuu of the latt^-r lae i-onncctcd to the former 
by ahurt laUrat I'f^mvnUma buiuK 

Ubturator Mdnbntiie it ■ llhnjiu structure flllin){ up the 
...ujr fonuuen cxiM-^it at it« U]if>er port, where uii uix'iiiug is 

Ftp. Ihl. 




vrt fiir the pasM^ of the ohtunitur visutel.t ami u>-rvi'. It give* 
to the fibres of the obturator extenius and intaniiM niu«<:1e» 
n-, ,..•. outer and iniK'r surfoceK 

Symphyala Pubia. — The two pubic bone* are united by an 
ml. t-Hrticnlur lilrro-ciirlilu>;euud four li;,'HUient». The anieriar pubic 
jomiM.til pOMM-K iu front of the two b<iiie!i, the nuiierliciul libies 
UUerlacin^ obliquely, and the deeper ones running truntversely. 



I'ig, IHl. — rtatmior li^nuails uf Uie pclvU >tnil bip-juiut (lliuiiuiiy And llii«u}, 

> p.-^»rn!^ '— '■-'''»' liirnoiml. 6. Tlu' «iii<i full) npuni'il by reniOTll 

I. . ' .. unrnC. of llie girat lignnirnt. 

; II ;u „:iiMciit. «S. Copsule oj Uip-joiiit. 

L SauU Bov-witttic liguiueut. 7. I'ontfnor «oito - vwuygenl Iig»» 

mcnt. 



386 



LIGAMENTS OF THE PELVIS. 



The potttrifir yuhic lu/nmait conaista merely of ji (■■ • 
6bres, 

The tvpmor pithu- lujuiiuiU connects the pubic crt'«t«. 

The iub-])ubic lujamnit ig a utrong band jiassing from ont ; i' 
Lone to the other, and arching l>eiicath the #yuiphy»i». ll 
closely related to the dorsal vein of the penis. 

[To see the nri-angenient of the inter-urlicular c«rtili^!e%l 
vertical transvei-se section of the symphysis near its posterior ; 
should be made with the saw.] 

The inter-aTiicvlar Jibro-caTiilaye intervenes between the rou 
grooved surface of each pubic bone, and is sometimes dividetl id 
two lamells by a small cavity containing tluid. ThL< joint i 
An example of amphiarthroeif). 










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388 



AitTERIES OF ABDOMEN. 



TABLE VIII.-AKTERIES OF ABliOMEX AND r«LVIS.| 

Abdominal Aohta. 

' CtrJiae ari*^ miscK npptrsitc upper border of let iuinhsr i 
1 (KoopliiiKi'al. 
O'anlrif . I C'orunury. 
( Onrcliac. 
I I'yloric. 



Brnnrhes to 
di|;e8tivi! 
viiceni 
(Bingle). 



Hepatit. 



. G.,tn,.U„„den»lU j 'C^Prrod^.'S . 



Spltnie . 



I I^'fC Imputii'. 

' Ilijrlit ln^piilii"^ — Brainli : cystic. 
Panoreutit'n* |mn"ie ct niagnu, 
GiiRtrir viidii i)rt'\-in, 
GHHtrn-epiploicu sinulm. 

Splciiii-. 

^uttgrwr menfn/rric, urucH oppflrtilu 1st lumbftr Ttrtebn. 
flriincb«i< til eninll iiiteDtinc : 

J'ttitcrrafn'O-iiutiiirtuUiM tH/rt'ior, 
Vnxii ititfxlifti tenuis. 
IlruTic'liPii t<i Inrgc intestine: 
Jteo-rolic. 
I (i/liea ilrllrn, 

I Inferiur iiiftrulrrie, ujaes opposite 3nl lumbar vrrtekn. 

! Siffiiwif/etr, 

! Superior htrtnorrhoidal. 
p. BrutitliPii to . Siiprn-riiiiil, niisrs opjHMilo upper part of Itt limibar 

iicin-rtiKe»tive J Itrital, arises <ip]>iMite lowBr part »( I»t luuilinr verlelir*. 
viscvru (pttire<l) | S/iermiit ic, urism opposite "Jnd luiiilinr veiiebru. 

rhreiiii\ firises dpiiosite upper Uiider of 1st lunibur rertfbn 
times one or botb from i-urlinc iixia or other bT^rcbef)^ 
Lumbnr, H«uiilly o on eai'h side. 
Anttriur liit'tkivit to ul>doniiniLl wjlls. 
J'oMterhr I MujintJnr braitrh lo erector spinm. 
tUvitioit I SpiHiilhraiii), u, •,|)in»l eolujun, memliraua 
ItumUA euniiliH anterior. 
Uan)us i-uiihILs pai.terior. 
Itunius mrdulbe ipinitlu. 
Sarru meiJttt (sHcnil itortu). 

' CummoH Jliticf. I>inull twin's to peritoneum, sub-perJt 
und urc'len. 

Su|ierior vesioU. 
Inleriorvesical — Branch : deft 
Obturutur. Bnnehes: iliHrxndiiul 
Middle bti'uiorrboidal . 
Hf.iiitic. 

Intemul pudic. Bnuiebra 
liir, vesual, inferior hirniorrl 
truniiverBe anterior niiil polMi 
IH'rinu'ul, artery to bulb, uttti 
corpus cavernoBum, and da 
artery of the p«iii.s. 
llio'lumbar. 
I.utiral !>ncml. 
, Gluteal, superficial 
Exfcriinl i/iar. Heioiues fenionilbelow 1' 
Detfi r\iiija>tr\e. Branchei>: pubic aiiii 
Jjff}! circwmftf ilioc. 



I'ariotal 
branches 



t. nrmiiHU 



JnUrnal ilinc, 

ttutfrior trunk. 



poiterior truiii 



rraj 



irnt 



"" ■■ ■'■,'^J 




NEItVKK OF AHUOMGN. 'WJ 

lu veinM correspond to the arteries, but the visccnil Vfiiiit from the 
nach, intestine, apleen and juincreaH form the portal vein, which 
tka up into a venonn plexiiH within the liver. From this plexux 
le the hepatic veins, the trunkw of which open into the inferior vemi 
a where it is imbedded in thu caval tissure of the liver. The imnic- 
te tributaries of tlie portal vein are the f^astrir, t)i(> Hjili^nic (which 
tally receives the inferior meiH-ntvric in aildition to thase corre8]M)ntiing 
the branches of the splenic art(>ry) and the supc-rior mesteuteriu. ip w. 
The veins of the non-di}^tive viscera and alMloniinal ])ariftes termi- 
te in the inferior vena cava, cxc(!pt the left HiKirmntic vein, which 
udly ends in the left renal. 

BLE IX.— THE SPINAL NEItVKS IN THK ABUOMKN AND PEIAIS. 
KBAn NaavBs: 

IMtrur tnnckft . . j JJ,^^„, Mu«uUr and cutam'.u.. 

(Int. 2n(l, .'inl iinfl 4th, with aiiiiinunirntini; Imtiich from 
I'ilh dnr»ul, furm Iiiiiilnir plrxiiH, and icive ott imall 
twiK* to qiiitdnitiiji luiiiborum. 
(12 II. 1 L.) Ilio- I Mux'uliir to traiiHi-i'nuiiis iind ohliqui abdomiuia. 

hjfpojtutrie .... \ Oiitaneouii i'.iar and hypoKiutrin bmnrhe*. 
(13 I). I L.) Ilio~ I MuM'nlar to tranHvcrmliH iiiul oliliqiii abdoniinia. 

imtmituil \ Cutanroiw tn thi|{h and Mrnitum or labium. 

(1 I). 2 L.) Oenilo- ) (Senilul or niuix-iilur to cri-iniiHtiT. 

emrml ( Crural nr nitHiiPouii to thiffh. 

(2 ft 3 L.) JSxltmal fHlimroHM (mv lowvr I'xln'inity). 
(2,3&4L.) jfrnterior erural (»'<■ lowpr extremity).' 
Within I HuKuliir to iliuiiia. 
pelris { Arterial to rxtrmal iliar. 
(2. 3ft4L.) (Aturmtor (*ee Iowit extnmity). 
(4tb) CummuHiealtHg to lumbo-Micral raid. 
Limbo-tatral eonl-Mi lumbar. 

:kaIi Nikvbs (aee lower rxtremity). 
RuUricr hrmuha. Miw-ular and eutani'oua. 
JUnUritT inuuhtt. With luniho-mrrai roni form Mcral pirxua. 

Smptrior gMfaf. (■> L. 1 S.) 

SmmU MeUtie. (a L. 1 & 2 S.) 

Inferimr flnUat (■omctimtii from atnall wiatir) S I.. 1 & 2 S. 

r»rf»rmttHf tHtmHeoHt to biittiH-k (» & 4 H.). 

Viieiral, joining »ympathi-tir. 

IPirifumiia (2 K.). 
Obturmtor intcmuK and gemnllua auperior (9 L. 1 S.). 
Quadratua fcmoriaand gemrllua inferior (twig to hip joint). 
Levator ani. 
Coeeygeua. 
External apbinrtcr. 
Onmt taatit (4 4e 6 L. 1. 2. :< & 4 S.). 
' Infanor hmnorrboidal. 

( Muaculnr to levator ani, iarhio-caromotua, bulbo- 
/Wk J Ptrimeal \ earemoaua, and aupcrfirial tranaremua pcrinB<i. 
' Cutaneoua to nrriniruni. 



(»ft4 8.)< 



n....\ „^^» nf ».„;. / Munrulor to deep Imnareraua perina-i. 
Donsl nerve of penia { CuJanooua to akm of penis. 




^' ^ 



PART IV. 



DISSECTION OF THE HEAD AND XECK. 

\Thc Slitdenl u requested to read the ' Introduction ' before ecmn 
iitg the diteection, vniett lie lias ihnt so on a precious oeeatum.] 

Bkkork l)cginuing the di&m-ction the stucletit sIiouM make Iiim« 
fully ncijuaiiited with the external conliguriition of the jMirt, anJ ih 
relation of Burface-markiiigs to deeper structures. If he has ttlrtaJr 
di8scct«d this region, be should nmke the iiiciidons nccessorr for 
cx]H>8iiig the uoiiiiiioii curotid iirtery and the thinl part uf the inb- 
clavinn artery, and may also advantageously perform the opermtjoai- 
of kryngotomy and tracheotuiuy, and practice extraction of 
teeth and the oj>eration for plugging the posterior nares, which 
can he done with a flexible catheter. V^arioug fKirtions of 
cranium can be recognised through the integuments, and should ' 
nott-d, as they may Ijc used hitt-r in ceroljral localisation. ThcT i 
the ijlaMla or niitnl eiiiiiieiiee, the breffmn, the lamMa, and 
niemal ixcipiial protHlxrance or inimi in the middle line ; and 
exto'itid atiijular procfst, the froutal em{ne)ii:e, the 2i/(iomulic nrrji, 
parietal eminence, the mastoid proccts, the lemportd ritltjr, and 
tajurior currrJ line on either side. 

The suiK-rficial appearances on the face will be describtsd mon_ 
jTarticularly imder that head, and reference may be made to 
section now, if time allows. 

In the neck, the median line is the boundary' of tlie dis!>ecttoBJ 
and presents the following prominences and depressions, fioin abov 
downwards. The 8ym)ihysis of the lower jaw ; a depn^cion cor»J 
res]X)nding to the interval between the anterior bellies of the 
two digastric muscles ; the pnyection of the hyoid bone. Hat 
greater conma of which can be felt running out almost huriioii- 
tally on each siile in some subjects ; the depression correspoaJ- 
ing to the tliyro-hyoid membrane (obliterated by Ute a^'cnt of lie 
ihytvid cartilage during degluUViun) -, tW '^vovuiuent ymnum Aaami 




THK SCALP. 391 

of the thynid eartilaf^ the well defined pit corresponding to the 
crioo-thyioid membrane ; and the prominent ring of the cricoid 
cartilage. Below this may occasionally be felt the uthmus of the 
thyroid body, and even the tracheii above and below it in a thin 
subject, and, lastly, the Bupni-8t4.'ninl Umm. On each side (portieu* 
larly in women) there is the slight projection of the lateral lobe of 
the thyroid body. 

The crico-thyroid membrane and the trachea should be especially 
noticed, as the positions in which laryngutomy and tracheotomy arc 
peifomied. 

The clavicle and stenium and the stenio-claviculur joints bound 
the dissection below, and across the side of the neck the prominence 
of the stemo-niastoid marks the divbion into anterior and posterior 
ttiangles ; in an injected Ixxiy the carotid artery may be felt near 
the middle of the anterior border of thi>« muscle. The external 
ji^ular vein, if full of bloml, will probably Ije seen crossing the 
•tnmo-mastoid obliiiuely, and may be ujiened seoinduin arteia by an 
incision parallel to the muwlv. 

After the dissection of tlie neck is coninienoed, ond sometimes 
before in thin subjects, two important Ixiny landmarku may be dis- 
tiagniahed, the pmmincnt tnmsverse prtx-ess of the atlas below tlte 
martoid process, and the anterior tubercle of the transverse process 
of the 6th cervical vertebra (earotid tubercle of C'liossaignac) nearly 
opposite the lower Iwrder of the cricoid cartila^t*. 

It will be found tu be impossible to dissect both xides of the head 
end neck simultaneously, and the students shouhl therefore ammge 
to work together, and to take turns at dissecting und reading. 

The diisection of both sides of the scalp should be completed on 
the fint day, in order that the broin may be removed on the second 
moniing. 

The Scalp. 

[The heed being shaved and raiHed on a Mock, one incision is to 
be earned from the root of the nose t<> the (iciripiit, und another nt 
right angles to it from the front of the car across the head to the 
correaponfiing point on the 0|>i>osite side, and the flaps thus marked 
out are to be dissected, Ixtgrnning at the to]i of tlie head, (ireat 
eeie naust be taken to remove oidy tlit; skin und nut the subcu- 
taneons tisanes, which are very thin ; the best ;{uiilt'S are the roots 
of the hair, which should Ix: exposed on the under surface of the 
flapib The flaps having been turned down to t)ie level of the brow 
in front, and the occipital ]>rotuberttnce liehind, the dissector may, 
if he choose, attempt to deKne the smidl muscles of the external 



392 



THE SCALP. 



ear, which are seldom well (l«vc*loiie<l. A portion of the walpmay W 
excised and its structure exuiiiined.] 

The Scalp contiists of many structures (Fig. ISi), In \hc \ 
covering tlie vertex tlieae are as follows, from williout in» 
] . Epidermu, covering the papilliE, prolonged iuto the Wr folli 




/% 



I:! 
It 



lUul continuous with the liniu};^ of the sudorii^iarouH and <5«biio?o 
ducts. 2. Cirfw rem, contnining sieliaceous follicles and amtla 
jnJorum muscles. 3. Faiinunlua iuli}>o«n», consiBting of o\<)iil lohuJt 
(if flit arranged side by side, with their long axes- at riyht angles to I 
surface. The hair Imlbs and gudi>ri]mviiiis coiLs lie in the upper I 



Fig. 182. — Seotion of the eoslp (iiftcr Poiricr). 



Arrsclom pilorum. 
Epidermis. 
Sobaccoiu glands. 
Cutia vern. 
Ititerlobulnr process. 
PnnniciiluB ndipoaus. 
Hair bulb. 



ft. Oslea njiOTieurotiea. 



9. Siidoripnraus f^Iiinil. 

10. Tt'bi (.'onjunotiTS- 

11. lntt'rb>bitbir pnictiSA i>f 

liiMue. 

12. Pericranium. 

13. Ilmnch nf temporal »rtet7. 

14. Rone. 




THE OCCIPITO-FRONTALIS. '.VXi 

Layer, and the tempoml and other vessels in the lower. 4. Oalea 
tmvtiea — ^the tendon of the occipito frontalis — covering the 
a. and prolonged laterally over the tem]N>nil faiw:ia and zygoma 
le lost upon the face. It is connected with the deep surface 
ifi detm by fibrous processes, which pass Itetwecn the fat lobules 
lA pannicttlna adipoeus. 

"he aeolp so constituted is connected with the ]M>rii;ranium by n 
e conn ective, tissue, ihs. td<k.(ii>ijunrtii-u, with largi! intercom- 
licating spaces. Any blood or pns effused in this Hulmponeurotic 
» tends to spread over the whole cranium, while like collections 
he scalp itself are sharply circumscribed. 

a the frontal and oeeipital rtgian* tlio galea aponcurotica in 
iilly replaced by the muscular fibres of the occipito-frontnlis ; 
in the temporal region the aponeurosis gireH attachniint to the 
irior and superior auricular muscles. 

"he Knacdea of the Pinna (Fig. 183), an- the imririilari* 
rior, the aurieularu anterior, and tlip niirieulariii jmnlfrior 
ittuu, attrahem and relrahtnut aurieulam). The niunes suiliciciitly 
eate their positions, and they arc all inwrted into tlu; pinna, 
anterior ariting from the anterior part of the n]x>n(>urusiR of tbi- 
pito-&ontaliH, and being inntrtnl into thi; helix ; tin; Huiierior 
PiEe middle part of the same aponuurosis, and wur.rtal into 
foMa of the antihelix ; and the posterior, wliich ronHixt'^ uf two 
liree stronger bundles of fibres, arising from the nia-<toid ]irocuHs 
passing to the bock of the concha. Tht-y rarely have any 
er of moving the pinna, but may slightly intMlify ilH Hhiipe, and 
anterior and superior muscles may act with the ocoi]iito-fnintalis 
maon of the galea aponeurotica. Minute intrinsic muscles arc 
present, but these will not repay di»Hertion. 

lie muscular fibres of the occipito-frontnlis are to Iw cleaned 
I on the forehead and on the occiput, curt; Iwing taken not to 
■ge the intervening aponeurosis, or tlie nerves which pierre 
muscle at several points and comnuinicHlu on its siibstunct' 



T 



he Ooalpito-fiK>ntalia (Fig. 183). — The nutenur MJy (2) ha> 
MOy attachment, but blends at its oriffiii with tlie iibrus of the 
enlaiis p alpeb rarum, pyramidalis iiatti, and corrugntor fupercilii. 
fOitonbrTt&y arita from the outer half or two-thirds of the 
aior curvedline of the occipital bone, and very Hiightly from 
nuntoid process of the temporal bone, and is sepai-uted from iu 
m ^a triangular interspace which is occu])icd by a prolongutioti 
le galea aponeurotica. Doth bellies are interted into the ^^len. 



394 



THE SCALP. 



The muscle wrinkles the forehead transversely, elevates the i 
and slightly aids in raising the ujijier lid : in i*oiue person* I 
also be made to move the entire Bculp backwards and forwarot I 
the ultemating contractions of its two l]ellie« ; and in aasiici.iticm with 
the auricular muscles it prol>ai)l y iiids the circulation of It mpll ia 
the H])nccs of the tela cotijunctiva by tensing the galea apouuur 
It is snjtplied \>y tlie facial nerve. 

'■ Cutaneous VesselB and Kerves (Figs, 183, 184' — '^" 
of t he car will be found brunches of the three division - 
nerve and branches of the facial nen'e, together with riiuji 
' oT the ophthalmic and temjioral vesseb. liehind the ear 
^vposterior auricular branch of the facial nerve, the auricular 
of the vagus, the great auricular and small occipital of the cer»'i 
plexus, the great occipital from tlie posterior branch of the secoi 
,»*erviial nerve, and souu'tiini's the third occipital from the thinl 
M^»y*r rervical nerve, together with tlie posterior auricular and occipital 
t_^*^ arteries. It must be borne in mind that the sensory btanche* 
of the 5th nen-e, although chietly important to the diaMCtor 
in their relation to the skin, give brajiches to the musclea with 
which they are in contact, and theae unite with the motor fila- 
ments derived from the facial nerve. In the limbs, both seniorA' 
and motor nerves are supplied to the musclea from a single nerrc 
^ktrunk. 

The Siijifo-orlnfal lurt* (8) [tiist.diy. pf 5th] will Us moat 
4'ound by feeling for the supra-orbital notch, and then cutting throi 
the ociMpifo-fronlalis at that spot. It_dividej_into tw<j br anchl 
within the orbit, the larjjer j^iussiiig through the notch or fonmirn, 
the r-nialler through a shallow groove internal to the notch. The 
twigs ]iierce the occipito-frontalis, and supply the skin nearly oi far 
as the laiubdoid suture. 

The Su]>ra-troch]faz nerre (6) [tirat «liv. of 6th] is u small nerve 
which leavesjhe orbit atits inner angle, and supplies the skjn 
the foreheiid«fter piercing the occipito-frontalis. 

Tlie Siipra-orbHal artery (Fig. 184, a) [ophthalmic] occompanii 
the supra-orbital nerve, and also gives superhcial branches to the 
occipito-frontalis muscle and integument. 

.The Fro ntal arteri/ (i) [ophthalmic] ia of small size, and aceos- 
panfer- tlie supra-trochlear nerve. 

Tlie Siijmt-orlnlal and Frontal ttiiis unite to fomi the an{;ul«r 
vein, which is the commenc«iiient of the facial vein ; they comms- 
nicate freely with the uphthnbaic vein. 

The Trmyoral Inamk of the Temjioro^malar ncrvt (Fig. 183, 

icond div. of 5th] will be touuA wilk difttulty, as it ia of small 



nene 
ani^^l 




NEBVE3 OF THE SCALP. -'^^<^'^ ^ ^P^. 



-;^ V^ 




ri|. 183. — XrrTO< of the acalp and face (from Ilincbfeld and LereilU). 



' Aatrrior auricular muiclo. 17' 

11 Aiittrior belly oroccipilo-frontalu. 18. 

|l Aiiriculo-t«tnpor«l nerve. 19. 

'■ Tmiiionil braiichi't of foiial nerve 20. 

(Tth.l. 21. 

. 8o|ini-auricular muH'le. 

• Supn-troc'lilrar ucrve Q5th). 22. 
|i' l'o«terior bcUv of occipito-fron- 23. 

Inlu. ■ 24. 

pn-ortiitiil nerve. 25. 

' Potteriur aurirular muacle. 26. 

> Tmiporel bramh of ti-mporo- 27. 

malur. 2S. 

• Snmll ocripitnl nen'c. 29. 

• Hilar brunrbeit of fnc-iiU nerve. 30. 
"wtcrior auricular nerve (7th). 

liUr bninrh of tcniporo-malar 31. 

mrre (Sth) (ramun (ubcutoneus 32. 

male). 33. 

•t occtpiu) nerve. 3i. 
\-orhiUil braache* of facial 

■ (rih). 




Foi'iiil ncrfo. 
Naml ni*rve fSth). 
Cervico-fnciiil diviaion of facial. 
Infm-oibitiil nerve (5th}. 
llninilicB lo dignitnc and atylo- 

hyoid (facial). 
Teuiporo-fiu'iul division of 7th. 
Greiit auricular tier\"t. 
UuL'cal bniuche* of focial neive. 
TrapcKiup. 
Huicnl nerve (olh). 
Snli'iauM capitis. 

Siorno-nmatoid. 

Supra -muxillar)' branches of facial 

nerve (7th). 
Supcrfitiul cervical nerve. 
Mcnl:il nen'o (6tli). 
riiitjsiiia. 
in fni-maxillary bran"ihe» ot t»e»\. 

nerve (7th). 



396 



THE SCALP. 



It pierces the tcmponil fascia imincdiuU-ly above the sygoma, 
distributed to the neighbouring akin 

The Avricnlo-UmjMiral iierre (3) [third div. of 5thJ lifa ima 
diately in Trout of the ear and close' to the7 teinportU 
Emerging from beneatli llie [lurotid glnnd it jnistes up the nidcj 
the LeHdj^tjLlkeJteuiporul^urtejTi', und, after giving bninches to i 
pinna above the meatus and to the ^aeatua_itself, is distributed j 
the skin of the temporal region. 

Temporal hranehet of the JtiQial. nrrve (4) [7thJ will be foa 
running obliquely over the xygoiun to tlie tciuple, where they j«i 
with the several branches of the 5th already descrit«?d, un<l supp 
the orbiculariB palptbrarum, the cornigntor sujicrcilii, th« nntei 
belly of the occipito-froiilalis, ami tlie anterior and superior auriciil 
mtiscles. 

The Temporal artery (6) [external carotid] is fonnd in front i 
the ear, and after jji^'ing o(f sonic Tnciul branches, an orbital brr^' 
which runs above the zygoma l>etween the layers jif th e teij 
fascia, it JTvides into anterior and posterior branches*. The 
lies upon the teniporarfascia, and is subcutaneous ; it r>>i 
fur forward as the forehead, and anastomoses with the supra^irbii 
artery. The posterior turns ba ck above the ear and una^tumcii 
with the occipital artery. 

The Temporal vfiii \ti forme<l by bninches corresponding to tha 
of the ai-fery, and enters the jiarotid glund to join the intenuil muxi] 
lory vein and form the teiuporo-nia.\illary trunk. The veins 
not accompany the arteries in the scalp. Both run in the do 
portion of the panniculus adiposHs, but the arteries relriict iu the 
tibrous canals when cut, while the veins, more iirmly attached 
the surrounding connective tissue tend to gape if divided. 

Surgery. — It is on the anterior branch of the temporal ar 
tlittt the operation of arteriotouiy is performed, when it is de^ir^l 
abstract blood from the head. In the operation it is nece»».irT ( 
make only a puncture in the artery, and, when sutKcient bfo 
hat Howed, to divide the vessel, in order that the ends may lie able to* 
retract and prevent the formation of a false aneurism. 

The Poderior Auricular tterve (13) [fucialj will be found 
diat^j j hfttiin d the ear, and running over the mastoid pro cew wt J 
_JV fVTMlBP"")''"" "rtery. It is distributed to the posterior bell>' 1 
the occipito-frontalis, to the posterior auricular muscles, and to (i 
-•superior if this be not supplied by the tem[x>ral branch ; as wrll 1 
the minute muscles of the posterior ]>art of the auricle. 
.Tie Foiiterwr .^iiricidar urter^ {J'\%. 181, 8) (external cwoli 



veasELs OF thk scalp. 



397 



aiterii' 



t the ni'Tvi' in thisi pnrt of iu couw*. mJ '• ?U«tri>>nt«jl 

I, anil by itjt »« ' ' 

. , ^Vlth the 1<!IIIJ10|U .1 

II o|Msna into the txtrrnal ju;{ulitr. 



rig. m. 




Fiir. IM. — ArU«ifa of tlu M-ulp and Au>e (after Htnle). 
1*2. (kriipiml Nrtery. 
iiKTv i:i. KckkI iirliMV. 

li. A> 'irviigeal urtary. 

l/>. Iin irlery. 

KS. 8t' I kninob of wcipttiil 

1 1 [ . aitrl \ - 

17. I.inRiPil .lltiT). 

III). IS. Sttrixi-iiiiutuiil krtiiiob of carotid 

artery anU url»'r) 

111. Subniriiirfl urtcry 

itcry. 'JO. Ilyuul liruiich iif liiiK'iul '■''tury. 

ti-ry. 21. Siipjirior thyroid artery . 



398 



THE SCALP. 



ls\ 



The Gir-- ^■-■■vla r iter ye (Fig. 163, 23) [2nd and 3rd 
nerves] a.-. .lie pinna, to which it gives nuinerouB our 

branches, jnmcijiaiJy on its posterior siirfHcS, forminj; a June 
\ trrmhe j>ostenor auri<iiilai' uerve. It Biippliu* ttJ«o a snuiU 
blanch to the skill over tlie niustuid process. 

Tlie ,S'i;iu// Occipilal nervf (11) [2nd, or 2nd and 3rd cer 
nerve] will be found about un inch behind tlie miiijtoid j>rqc«a» i 
at tlie poSWTtsr margin of the st emo-ina-st oid. It is u small nc 
and passes directly iipwards to supply the scalp, giving also 
sionnlly a branch to tLe pinna. 

The Great Occijntal nerve (i^) [posterior division of 2nd ccr 
nerve] is a large nen'e, andjffL'Lbe found piercing' the trap 
muscle near the occipital protuberance. Its branches lie over 
posterior part of The occipito-frontalis and are distributwl to 
scalp, communicating with the small occi|)itul nerve and wiH 
"ffeUow nerve of the opposite sjvle. 

The Third or SnuilUM Occipital nerve ix an occofiional bnuich ; 
the posterior division of the 31x1 cervical nerve, distributed lo 
occipital region internrtlly to the great occi|iital. 

The Occipital Artery {Fif;. 184, 12) [external carotid] lies clfl 
to the great occipital nerve, but its relation to it is inconstant, 
ramifies on the back of the pcalp, anastomosing with the artery ( 
the opposite side, and with tLe posterior auricular and temf 
arteries of the same side. The vein usually joins the deyi 
beneath the couijilexus muscle. 

The Temporal Fascia will be fully exposed by removing 1 
temporal artery and the branches of nerves over it. It is alia 
above to the superior tempoi-al ridge on the frontal, ]>arietal, 
temporal bones, and bel<jw it splits to be connected to both lig 
of the upper border of the zygoma, enclosing between its lay* 
some fat, a small orliital brunch of the temporal artery, an 
the temporal branch of the orbital nerve from the euperid 
maxillary. It is pierceii by the luidJle temporal artery and 
temporal branch of the orbital nerve, tmd gives origin by its de 
surface to fibres of the temporal muscle. It is reUxted extenudly 
to the temporal portion of the galea aponeurotica which jiaA^es 
downwards over the zygoma to the face ; and internally is sepa- 
rated from the temporal muscle by a quantity of fat. 
. The Temporal Muscle will be exi>osed in part by removing til 
fascia covering it. It arine* from the frontal sphenoid parietal 1 
' temporal bones, between the superior temporal ridge and 
pterygoid ridge of the sphenoid, and from the umler surface of tliej 
ti-wporal fascia. Its tibrea aiu aeciv to cotivar^ to a tendon, wLidtj 



r^. 




THE LYMPHATICS Or TliE SCALP. 



899 



be foas<l in a tQb««quent diBScction to 1>c interUd into tbr tip 
■ltd inner upect of the coronoiil pnxress of the lower jiiw. 

lie Ziympb&tioa of the ecatji (Fi>;. 1>*5), uiv clcwely iisunointati 
jhe veijK. The mij fronlAl n-gion, together with tht fucv, i» 

»*♦ 

,#♦ Pif. IM. 




R(. lU.— Diagrun •boTiog the tupertirinl Ivmphiitic rvgioni of the hnd nnt 
neck. (W. A.) 

(Hm deep oerrical gUndi arc iodionteil by lighter ibading). 



400 



REMOVAL OF THE BBAIN. 



drauic>d by the tubmaxillaTy glands ; tlie lateral fronUl and 
anterior leinpoi-o-parictal regions (in front of a line drawn vertir* 
upwards from the jiiiina), by the pre-auricutar or yarotid gli 
whioli overlie the paixitid salivary ^doncl, and jtartly by the sg 
muxillory gland ; the jjostcrior p<irieto-teuiporal rej{ion by 
mantoid or retro-aiirirular glands upon the mastoid procea* ; 
occipital region by the occipitul glands Ijnng below the 
curved line of the occipital bone. An enlargement of the i 
aud mastoid glands, with ]ierhap8 the posterior cervical chain, it 
usually au indication of scalp irritation by pediculi. The l;mji 
from all these Bources is eventually ]ioured into Uic deep cervix 
glands. 

Rbmovai. ok the Brain. 

[Koth si<les of the ^'alp having l>een dissected, the knife thoQ 
be dniwn amuud the .skull, marking out a line an inch ab<>ve i' 
orbit in fiont, aud hiilf an inch above the (K^cipilal }irutuberon 
behind, and passing ihrougb the temporal miibcle between thn 
point-.. The outer jdate of the skidl is to be isawn through, hinxii 
care being taken at tlie iinterior and jiosterior extremitita of lb 
temporal ridge, and at the occiput. With the chisel the remainin 
thickuess of the skull can then be readily divided without iujnrij 
the brain, aud the calvaria may be removed.]. 

Upon Removing the Skull-cap will be seen the rough cm^ 
surliicc of the dura muter, aud it should be noticed that it fornii 
the internal periosteum of the calvaria, now left bare. The inner 
surface of the ^uU-cap presents a longitudinal groove nearly in 
the median line, correspoudiug to the supei-ior longitudinal sinua, 
and joining tlie grooves for the latend sinus, usually a little 
the light (if the middle line and opposite the external occipit) 
protuljeiiiiice. On each side of tlie longitudinal groove 
frequently lie seen dejiressions of variable size, CDrreaponding 
the Pacchionian bodies. The grooves for the middle niening 
vessels will be seen chielly on the inner surface of the pane 
and tempoial bones. The Dura mater is cream coloured, but oftO) 
has u bluish ajijiearance when its Iranslucency allows the vtifll, 
of the surface of the bmin to be ]>artially seen. On each tid* 
of the middle liue are usually found the Finxkitmian ^k^] 
liypertiriphied villi of the arachnoid, )>rojectiug tlirough tli»1 
dura mater and imlenting the skull. Kamifying upon the dBr»j 
mater is the lai'ge middle inenimjuil artery [intenial maxilJ&T^J, ( 
and in a well-injected body the niitmor mtninyenl [etJimijidalJ anil . 
jtmteriur menmyenl (asceiuliug pharyngeal) may siinietiiuee le seea. 




REMOVAL OF THK HKAIN. 401 

he meninfjeal arteries are the princi]ial nutrient vcmeh of the 
anes u well aa of the meiubmne*. 

Tke Meningeal Veine (vente cniniteM) accompany the arterieti, 
oA tenninate chietly in the inteniul oiaxillnry, ctbuioiilal, verte- 
mI, aacending pharynKeal, and occipital veiuM, and in the 8itiuii«8 
r the dnra mater. 

The Binueea are the intracranial canals in wliich terminate the 
una of the brain, orbit, and diploT*. They differ from the ordi- 
uy Tcina, (1) in the rijrid luilure of their walln, whivli consist 
r a layer of the dura muter linetl with venous endutheliuni, and 
iiiiMn patent when divided ; (2) in having no valves ; und (3) in 
lat their tributaripA join them in a <lirection contrary to that of the 
inent of blood within thum. 

The Superior Ijongltudinal BinUB (Fi^. 1 Mfi, i ) should Iw 
xned at once. It ciiiiinieni.'es in a sntull vein, which enters the 
rail from the nose through the foramen ca>cuni, und, running; along 
le whole length of the upper lionler of the fa].\ cerebri, it ends in 
le right lateral sinus. It is fomieil by u splitting of the dura 
■ter, and its canal is triangular in section, and traversed by snutU 
ndinous cords (chortbr inilinii). It receives suiierior cei-ebml, 
ploic, meningeal, and i>ericninial veins (through the ]>urietnl 
mmina) ; the orifices of its tributaries all poiiiliug from iKihiud 
rwards, i.e. in the opiH>site direction to the current of bloml in 
e ainiu itaelf. 

[Tie dnra muter is to K' divideil longitudinally on each side of 
a Hnoa and turned down. Dy this means the miIhIuiiiI simce will 
opened, and the antehnoid membrane will be seen rolb-ctetl over 
t jAn mater covering thv. brain. By slightly separating the two 
miapheres of the brain with the hau<lle of the kuile, the falx eere- 
[ will be exposeil, und nijist l>e detucheil from the crista g-alli of the 
unoid bone.] 

Bamoral of the ^rain. — The head l>cing tilted a little back- 
ida, the anterior loWs of the cerebrum are to be raised, when the 
betoTjf n«rrv« and bulbs (1st ]>air) will ]irobably liu debiched 
tfa thiem from the cribriform plate of the ethuKiid bone, or if 
iffueyeui be reatlily displaced with the handle of the knife. The 
tie Ntixe$ (2nd pair) of large size, will Im* seen close to the anterior 
Boid processes, and should be divideil, when the Internal Carotid 
teiiee will be brought into view, and must also be cut, togi-ther 
th the infundibuliim attached to tlie pituitnni IkhI)/ in the luiildle 
e. The 3nl pair (nwtorei oeiilorum) will be seen piercing the 
la mater behind and a little external to the carotid arteries, aud. 

W. D D 



402 




REM0V4X, OF THK BHAJW. 



behind the onterior clinoM proieiw, anil after dividing tfaeie, 
ttntfrrium crrthelli will hi- lironglit into view, with the sleluliT < 
lierve (palhfiicM rel irurhUiiri*) oil cacli side, at tlje fxiint of 
decussation between its free and attached borrlers, a 111 tie li«li 
and exlenml to the posterior clinoid [iroceju. The fetitoria 
be divided on cnch side by carrjing the knife backwanli i 
wunls, parallel to the margin of tin- jietivus bone, au<l the 4lh | 
will be cut at the same time. The tentorium having been tur 
aside, the remaining cranial nerves will bo exposed, and mu»t he 
cut, in their numerical onler. The filh jiair (tri/ncial) will 1« found 
lo lie composed each of two rc»ols, the lar^^er and snjjerior one Iwing 
chiefly sensory, and the deeper, which is anterior at it" .*. - 
chiefly motor in function. The 6tli jiair (abducenUs) lie m-.r 
meilian line lielow the posterior clinoid proce.sses. The 7lli • 
Jnrial, and the 8th or auditory, the latter behind and Wlow the 
former and connecteil with il by a bund of tibres ciilled the i 
tennedia, are seen on each side eiiteriiif; the internal a 
meatus with the auditory vessels. The S)th nerve or ytotn.'-yii ■ '■ 
grat runs with the 10th or ritijiui, and the 1 1th or tpinnl no- • <•>, 
to pierce the duni muter at a i)oint externid to the jugular cminrnt* 
of the occi|)itjd bone, and appear in the angle lietween the Ut< 
and inferior petra^al sinuses, where these are about to pi*Tce 
jugular foramen U-fore uiiititig to form the Jugular vein. The J 
the highest of tlii^ three, and has A separate dura! aperture, while I 
11th is Joine<l by spinal tilameiits which jkisr upwanis from 
spinal canal. The three nerves disappear through the foramen i 
ritm poslrriut or jugular foratuen with the sinw-ses naincil. Thr 123 
(hypnijlossal) nerve comjsUi of two bundles placed near the niiitiiii 
line, which pienre the ilura mater separately between the jii;,nil4r 
eminence ajid foramen magnum and then fia-w together tlirough 
the niilerwr comlyloui fommrrn.. At the jioint of juiicfii'ii betirwo 
the falx cerebri and the tentorium will be found the nfntujht liai, 
joining the lateral and sujwrior longitudinal sinuses at the l<^in:BUr 
Hcrophili : it receives anteriorly the iiifrriur Umyitudinal ti%% 
which run.s in the free border of the falx cerebri, and the 
of GaUii, jNitsing from the velum interpositum ; and in its tx 
it is joined by the mperior cerebellar reim. 

The knife is now to be pushed through thi: foramen mognnm J 
as to divide all the parts passing into the skull, viz., the apiDtlt 
and its membranes, the two vertebral arteries, the Nimdl »pEl 
vessels, and the two sjiinal-accessory nerves ; aiid it sliould 
noticed that the cord can be cut considerably lower than the 
bich the vertebral arteried enVCY \Jtk« »Y^\\a.l catial. The hn 




SINUSES OK THE DUllA MATKK. 40.'l 

can now lie lifted out of the vkull, by Hlippiug the fiiigen beneath 
the cerebellum and allowiug the h<wi tu fall buuk. 

E (Before plocini' the brain iu methykted rtpirit, the tliMxectorssliould 
'ck olT the arachnoid and the pia nmlvr fruin tiiu Inim-, and carefully 
y out thenerveii in their pni])(>r iKMitions, taking cure not to interfere 
with the urterim. The brain ithould !« plaue<l in u ]>iiii with the baae 
apwonlK, and with a piece uf rulicu lianiluKe bcueatli it, so that it may 
be eaaily lifted out ; but if it is too deconiiHMe<I to lio worth pre- 
aerving,' the venwlii at its iNiae should Im- dinscctctl at once. After 
removal of the brain the ]Niints of exit of the various nc-rves should 
be uMrefully examiuol ut tin- Imisi- of the skull. | 

The Ucra Matek .\ni> Sim'hkk of thk .Skull. 

The Dura ICater is a Ktruut; fibrous nuMubnuie lined intcnially 
with eiidotheliuut, and finuly attached by itx out<-r surface to thn bare 
of the skull, especially at the sutures. It sends jirucesiii-s through 
the several foramina to form shi-atlis fur tlu- uvrvis, and splits in 
eertain situations to fonii thi- sinusi!>i, and to imicUim; the Gosserian 
guglion and pituitary btMly. It is iiitlect<-(l to form three pro- 
eeMes, the falx cerebri, the falx cei-elwlli, iiml the tentorium 
eerebelli ; and 1>elow is rontinuous with th<- dura mater of the 
spinal cord through the forauu-n magnum, to the margin of which it 
is doaely attached. 

The Talx Cerebri (Fig. IHIi, 3) <ir /x/x- ;ii'//''/i- is a vi-rticul 
oickle-ahaped process of dura mater, plout-d UawtM-n the two hemi- 
sphena of the cerebrum. Alxive it is coiivi-x ami •oniiectud to the 
aknll in the middle lini-, Iwlow it is five and coiii'uvi-, and isdiivctinl 
towanU, though it does not artually reach, th<! roriuis callosum. 
It ia attached in frtmt to the crista galli of th<; ethmoid bone ; 
■ad behind, where it is much <lcei>er, to the iuti-riial ocri])ital ]>ro- 
taberance aiid to tlie mid-line of the tentorium I'lrclielli. The 
alienor and inferior longitudinal sinuses run ulout; its upper and 
lower borders, and the straight sinus lies iM-twet-n it and the ten- 
torinm. 

The Tmtorium Cerebelli (Fig. IHO, 8) is tin: |>io<'c><s of dura 
mater placed between the cerebrum and cei-elMdluiu. Wlion perfect 
ita free niHigin bounds un oval uiM-ning, through which i>aM the 
erma oeiebii with the corpora <|Uadrigemina, the superior peduncles 
of the ecTebellum, and the {losterior cerebral arteries. It is attached 
in front to the anterior and posterior clinoid proceswi.'-i of thr sphenoid 
bona, and to the superior border uf the {M-trous bone, there splitting 
toCotm the auperioi petioaal sinus ; and behind, to the niarr;iua of the 

u u 2 



404 



SINUSES OF THE Dl'RA MATEB. 



ove for the kteral sinus on the occipital, jvirieta], and temponJ 
Pbones. 

The Palx Cerebelli (Fig. 186, 14), or faU minor lie* Uk 
the tentorium in the uie<iian line, ami is uttuclieJ to the uieU 
ridge of the occipital bone nearly ns far us the foramen luiij^iiin 
It is of small pn>iuiuenc« and generally (Uvides below, mh 
slip to each side of the foramen moguum. 

Fi«. 186. 



Wl^^.>. 



i„a'r 



^;^ 




The Inferior Iiongitudinal Sinus (Fig. 186, 4) rans uloi^ 
the lower border of the falx major. It \» much smaller tlum 



Fig. 188.— SinuM* of the skull 


(aide view 


i 

} (from HirMbield and Lereillrt 


1. Sumriur longitUiUnnl iiinus. 
2 Fiilx wrebri. 


H. 


P'nlx cerebelli. 


1.5. 


(ith nerve. 


3 6th ni-Tvc. 


111. 


'.'til, 10th and 11th nerrei. 


4. Inferior longitudinal aiuua. 


17. 


7th and 8Ui nerre*. 


5. 4tU nerve. 


18. 


Vertebn*! artery. 


6. VuMir G«leni. 


19, 


Euslachian tulw. 


7. 3rd nerve. 


•JO. 


1st lervical nerre. 


8. Tentorium cerebelli. 


-21. 


l'2th nerve. 


n. 2nil nerve. 


•n. 


Posterior root of 2nd arnaS 


lU. Struiglit sinus. 




nervo. 


11. Crista gAlli of ethmoid. 


23. 


Anterior root of 2nd eerriMl 


12. Toreukr Herophili. 




nerve. 


Id. Ul nerre. 


IK. 


lA^am^mtAm dQuticuL&tUflu 




longitiiiliiml slnos (i), aji<i tunn mciic rtMitmlitance to u true 
X lie^uit ubimi the niiJJlr nf tlu; fulx iiinl opena into the 
kitlUr. 

tr»ight 8i&u* (Kig. IH6, lo) mu«t be <>)>viiv>l along tlie 
ittachmeiit or tti<- fnlx to the teiitoriuiii. It i» funueil by 
111 of the tmie <,'iilrui of the bruui witli the lliferinr longi- 

siniu, nixl iTt-eiver the siiiitrior cereljcllur veins. It up«na i 
hfTtular Hfrophili, uuJ thus coliiiectii the two longitlldtiud 

Occipital Binus (Fig. 1A7, i8) ia fnrnieil by a apUttiiiB 

fnlx cerelielli. It coiiuiiunicateH aboTC with the torcalar 

ill, and bifiucat«« below to join tlie posterior spiiinl veina, 

icIjc* reMliing on each side «a far ni the lnwer end of the 

\in\i*. 

X'oroulax' HerophUi (Fig. 187, 3t) i* the meeting point 

■uperior ]iaif,'ilU(Iinul, Ktmight, orcipitAt nnd tn'<i Interiil 
It i» utiuilly sitiiiitud on tlin rl^ht of the internal occipitAl 
nuinc, but Kometinics to it« left.* The occipital diploic 
Kntnonlr open into it. 

liateral Sinuses (Pig. 187, 20), the Ur„'e«t, commence at 
Cular Ik-ruphili, and take a cur^ecl course to the forumeu 

on each side. It is neceiuar^' to cut tlirough tlic tentorium 

to expoac the cavity of the sinus, which will lie found to 
Ihe occipitAl, parietal, and tcinponil bones, and the occipital 
ptin close Ui the jugnliir prtK'css, It rrfrwu the superior 

sinus, the posterior ti-ni]Kiriil (unl sonietinii's the occipital 

reins, ond tlie inferior cerebnil und cei-eljellar vein* ; and., 

\\ca.\e* with the veins of the exterior through the maattiit 

Iterior condyloid foramina. Finally, after passing througll 

linen lacerum jHj»-terlu», it U joined by the inferior petrosal^ 

tnd fonns liie iutenud jugular vein, returning nearly the 

if the blmnl fwm the bmin ; the interval between the two 

Rt the fonuwon lacerum postering being occupied by the Wth, 

111 1 1th nervex. The lateral niuus which receives the superior 

is usually larger ilian it* fellow, 
portion of the vessel below (he tentorium, grooving the 

portion of the leiujHiral and the jugular process of the 
. buiie, is sonietiuicu) known as the tiijmoid tinui, 

Illy the Inncit't'linnl Mniis brrome* dilated n littlo to one tids of the 
HIT tJie right itiili<, I'oriiiin^ the torciiUrJ 
I ' llu' rorre»|K.niling Intcnil tuiiu. Thai 
.arrdl ainua iif tliu iip|Kitite tide, uml a itomi 
;> fpjiii tile lurculsr III the point st which it 
^Itt a* the cue lull V tM. 



•wo 



KINUSES or THE DURA MAIKK. 



The Superior Petrosal Sinus (Fig. 187, 12; will U- rtf 
by runniug the kiiil'e along tho iipix-T bonier of the pi-troii* l"1 
from which the tentorium wns detiiclieil. It of small -iie. 
runs from tbe CAvemous siiius back to the laf>riil sinn*, jii'l «h« 

Fig. 187. 




the latter turns do>vii wards in the temjuiriil boiic. It rvceivw tri- 
butaries from the cerebrum, ceivbtUum, anil inlenial ear. 

The Inferior Petrosal Sinus (Fig. 187, 14) will be ci|>K&«d by 
cnnying the knife from the foranien juguliire, liiiectly forwsnU 



Fig. 187. — Diwertion of the ninuws 
caremoua ciuus iliii«cctod on the I 

1. 3rd nerve. 

2. Optic nerve. 

5. 4tn nerve. 

4. Intcmnl carotid artery. 

6. GusMiian eanglion of fitli nerve, 

with it » three diTisioni. 

6. Circular ciniK. 

7. Superficial petrosal nerve. 

8. Cnvoriious miiuk.* 
y. 6th nerve. 



f the aktill and I'rauial ii«rvr», thi- 
eft hide (drawn by J. T. (Jmy) 

10. 'I'ransvcrM or basilai sinu». 

11. 7th and 8th nerveH. 
\'2. Superior peti'o»jil iiuius 
i:i. Otii, Kith and Utli uerviu. 
14. Inl'erior petrosal ^uiua. 
16. 12th nerve of left ride. 
18. Ui'vijiitul <iitus. 

20. Lateral siuua. 

21. Tonular IlerophUi. 



* The apbcDO-parietnl sinus elinuld he rcpre^-nted as extending alunt tlifl 
potterior border of tho leaser wing ot Ihe <if\kena\<i \nuvun «i\<i \.\\\v 






THE OASSKKIAN (iANiJMON. 407 

along the lower bonier of tin- |H'trriUK Imiik! lit tho jHotfrior cliiioid 
proceiw. It cotuniunicitteM in frunt with the fiivcriiiiu.s xiiiiH, and 
behind with the internal juifiilur vi^in, after iiuxsin;; tliniii;;li the 
foramen jiij;ulare in front uf the Otli, 10th, anil Ilth uiTvi-n ; and 
u brou;;Ut into connection with it.i fellow liy tin; transverse "r 
baailar sinus ( lo), which erosMfi the liit-ihir ])rocr.-« of the 
occipital Uuie. 

The Cavernous Sinus (Ki^. I-ST, Hi in ]>lui-fil hv thi> fUU- of the 
pituitarv hotly, and rviiuire^ can-fiil diMici-liun on ai't'ount of the 
iierveo in relation with it. Thc.<e an- the :iiil, 4lh, niihthalinii-. 
divigian of the oth, and Uth, and their |Mi>itiiiUh ^hnuhl he ut onee 
awertaineil. The :)nl, of ffuA >i/e (i), will In- reci>^ni/.eil idnsu 
behind the anterior elinoid )iriii-es.s ; the 4th, ven small (,{), at the 
point of decussation of the fiee and altaehed Imiilers of the tento- 
rium ; the entire 5tli nerve, lur;;er than the others and .■.nnivwhat 
flattened out (5), is seen ininieiliutely heneath the teiituriiini ; 
and the Rth, ]>ieivin;; the dura mater nearer the median line, ujion 
the Imsihir process, ulN>nt half an inch In-lnw the iiosterinr rlinnid 
process '9). The sinus n-ceiven the circular, the >u|ieri(ir iHftn>sal, 
and the Hpheno-parietal sinuses, the i>|ilithalnii<' vein, and a emu. 
municating rein from the ]itri'y};<>iil |ile.\Uh throii;;h the foramen 
laceruni medium. 

STlie left sinus will U: fimnd the mi»l convenient, for di.-<M'ctii)ri, 
1 should theivforc Iw taken first. The Ith iiei ve i^ to lie i'iilh>wed 
out carefully to the sphenoidal Iispuik hy dividin;; the duia matttr 
with a shurji knife, and the 'Anl shouM lie taken next. Thi; dura 
mater over the r>th, Imvio}; Iteen freely divided, sliuuld he torn up 
from the hone, hy which means and a very little dissectinn, the 
Gosiierian Ki^n;;lion and middle meniu^^eal artery will In- liroii^^ht 
fully into view.] 

The Circular Sinus surrouniU the ]iitiiitary Imdy, and l>riri<{s 
into communication the two cavernous ninn.-es. 

The Bpheno-parietal Sinus is a ^mall vesM-I running' in the 
fold of dura mater over the |s>.<terior horiler of the le»er wiiii{ of 
sphenoid. It receives Mime anterior temjioral diploic vi'iu-> and 
ends in the cavernous sinux. 

The Oasserian Oanglion Fi<;. IS7, 5 , the \nvn>-^l of the 
cranial gati<;Iia, is of a pinkish colour, and is placed in a nliallow 
fossa ufion the ti]i of the su]ierior >uriace of the petruii-i |uirtion of 
the tem|M)raI bone, enclosed in a kind of pouch of dura mati-r known 
H the iipoM of Mtekel. It \> fonneil upon the larger or sensory 
portion of the Otli, and the smaller or motor |iortiou pa»»es heneath 
it From the gSDjflioii the thive •^khI divisions of the .'>lli ate \n 



408 



SINUSES OF THE DURA MATER. 



be tmceil a« follows : — The first or ophthalmic Jivuion to 
sphcnoichil fissure ; the second or s\iperior muxillarv ilivuimi lu I 
foramen rotiindum ; nnd the thinl or inferior iimxillary divimtm'l 
the foramen ovule. The motor trunk of the nerve join* lhi« 
division outside the skull, after passing through the foramen ov« 
The ophthalmic division is seen to pas« along the outer side of 
Icavernous sinus, and to give off its nanal branch and a miuQ 
recurrent branch (Arnold) to the tentorium cere belli before 
enters the sphenoidal fissure. 

A small Tfumnt twig given off outside the skull from the 
division of the 5th enters the cranium through the foiunien »fb 
sura, and divides into two branches, one of which supplies 
great wing of the sphenoid, the other jiierces the jieiro-iwiuaino 
suture to end in the mucous membrane of the mastoid celU. 

[The (Jth nerve is to lie fullowed by dividing the dura mater oii 
it, and will be found tu lie against the outer side of the carot* 
artery, where this makes iu sigmoid turn at the side of the 

Fig. 188. 



Srd nerve . . 
•1th ncrre . . 

5th nerve . . 
6th m-rvc . . 

Iiun mater 




Veuoiu canul. 



lutoraui carotiil. 



^turcica. The vessel should be fully defined, and an attempt mn 
to see the ramtid plexus of the .sympathetic u|Min it. from which 
brnnch guvs to join the 6th. It will render tlie dissection mu 
useful, if a small jiiece of the lesser wing of the sphenoid is clipp 
olf with the bone forceps »<i iw to open up the sphenoidal fissure, ua 
tiie nerves can theu be carefully foUnwed to their entrv into tli 
orbit.] 

The 3rd and 4th nerves, and the first division of the 6lh nervj 
have been seen to lie in the outer wall of the cnrernotu nnn 
immeiliately beueath the dura luater ; and between them jin 
the 6th nerve, which is placed against the carotid arteiy, is tit 



Fig. 188.— lliugmin of left i-avrmou* linii* seen in teotion from hehisd 



THE CAVEKXOUS SI.VU8. 



4()i) 



throu|;li wljirh lite bU<od i» n-tunii'J from the orbit, 
h!« i« very <ii'li<iito, lunl ran i-t-lilom Ix- ilrt'im-"! ; it receive* 
*i'' vein, tin' Kjilieiiii-|>HMitnl «iiiiiM, tbv circillnr linua, 

M>d a ■ tbf (•leryxiiul plvvii" liin>iit(li the furanicu locermu 

mnliuni, lUiU <ijwii» into the two pelrumil aiiitiwn (Fix- 188). 

Til** Ivlatiuu which tiie uerveb huld tu one another in the cav«rnoiii> 

*i]iu« ia III (it*t from nbove downwanl* accordinj; to their nmmrieal 

"■'»r — i.t. 3, 4, 5, (1. B*tforc they rciich the orbit, however, they 

-<■ their rehitive positioni, nml nt the uphenoiilAl ii»»nre itre 

ji.i.rtl roughly M followd, from «l)ove dowinvunl — 4, !\, 3, fi. 

If the AiiKurc hftH Uh-ii i>i>*<nt'il up a* inlviwd, ami the dia*ection 

i>r rarrfully uiaile, the 3rl lirrve liefort- ent»Tiii>; the orliit will be 

f.ionil 111 iliviilr into two purtii (between which the naxjil branch 

. ttiid tlie fttb, nftcr giving olf the iiomrI 

mint and Itwhrynuil bmnche:^. The order 

' I iiv;h thf opheuuidal rt«*ure, from obove 

■■■ ■■■• ;i» foUowH (Fig. 1S9) : — 

( Fourth nerve. 
iFro: 



I AboT« the mtucloL 



I tbe h«td* of 
•xttrnal ivcttu. 



Frontal und lachrymal ncr\e3 [5tk]. 

, Upper division of 3rd ner^'e. | 
Kami braiji-h of 5th nerve. ) 
Lower divixion of 3nl nerve. ( 
Sixth nerve. | 



^ 0)ihtlialmic vein (most internally). 

yig. 188. Caramout Hlnua. 




(ittuMorijin 
Oniiglion. 



[Th« Internal Carotid Artery (Fig. 187, 4) should be traced to 
' ttpjier opt- ning of the carotid canal at the apex of the petrouR 

Fif. iif.—Pitgmm of the nfirt* /xvinK through lh« mveraotti tinui 
(dnwii b} J. T. Gny). 



410 



SINUSES OF IHK UURA IIATKU 



bone. It Diaket) a sigmoid turn by the .-.iili; of the ?ellu tti 
nnd then wjiid* closu behind the anterior cliiioid jiriH-j-i<s whrret 
was cut in removing the bruin. Ii> a well-injected IhnJv, a fl) 
small branches (nrteriae Tecfpluciili) appear in the lyivertii'iln all) 
going to the dura niatej- ; an<l thi- ophthalmic artiTV will be 
entering the optic foramen to the outer aide of the optic nrrrc. 

Sympathetic Nerve.— A network of tilttmeniM nii»y Ix- ir 
upon the outer aide of the carotid artery in the carotid cjtnal, for 
ing the carotid yteius ; this receives an ascending brauch trvmi 
superior cervical ganglion and givea lirauchcH of comuiunicotion I 
the &ixth nerve, the GoHserian ganglion, Meckel's) ganglion (by i 
d(tj) petriital), and .Tncobson'i. nerve. The aietniout pUxtu may 1 
found on the inner bide of the artery close to the anterior clin 
process ; from it paws twigw of commuuiciition to the iin\, 4tli, 
and (5th cmnial nerves and the lenliculiir ganglion. 

By diiiplucing the Gaitserian giinglion will be seen n little gruoV 
in the upper surface of the petrous bune, conducting u »mull uer 
and artery to the hiatus Fallopii, through which they diaap] 
They lire the (trealer tujierfirial jietrinuil nerve ami arter>', the not 
the contliitiation of the Vidian, going to join the lucial, and 
artery a branch of the middle meningeal. Two other nerves m 
be found entering the tempond bone, on the outer side of the hiatfl 
Fallopii ; one, the imaU tuprrjirinl petrotat, is tlie cominiiiiicali 
between the facial nerve and the otic ganglion ; the other, til 
fjifTiml sujKrficial petrosal, also pa-Kiiing to the facial ner\'e, in derive 
from the sympathetic on the middle meningeal artery. 

Meningeal Arteries. — The Antrriur Mfiiinijnil Artrrif fnil 
the ethmoidal iirlerieji, if injected, will lie seen to enter thu cruiiil] 
thnnigh the ethmoidal foramina. 

The Miildlc Meiiingral Artfrii can be seen entering at the fontnM 
itpiuotium. It ramifies on the outside of the dura water, and diviJ 
into two branches, an anterior, whii'h grooves deeply the tip of tk 
great wing of the sphenoid and the anterior inferior angle of th 
parietal bone, and a i>osierior crossing the squamous }>ortiuu of 
temporal hone to reach the parietal bone near the middlv of 
lower border. It supplies nearly the whole of the dura nialer > 
crnnijil bones, and gives small twigs to the facial and tifth nerve 
to the orbit, and to the teiu]>oral fossa. It is accompanieil by toii 
comitff, and by a plexus of sympulhflic ner\es derived from 
superior cervical ganglion. The middle meliiugeal /■ 
filaments to the otic ganglion und to the intuiuescenlia 
of the facial nerve {external pelromil). 

The Small Meningeai Art«ri| u & VitiacVv ot vVie uoertuU uaxiUi 
or middle meni ngeal, and enters t.\\e sVlmW iVtcw^ vltwi Koymvustx wi 




POSTERIOR TRIANOLK OP NKUK. 4>11 

The Meningeal Branch of the Aiee»diH(i J'haryntieal arterj' may lie 
fotmd petfonting the foramen laceruni medium. 

The Poeterior Meningeal Artmee are Hmall bronRlicR of tlut occi- 
pital and Tertebral, which enter by the fomiiien jiiKulurc anil 
foramen magnam respectively. 

The Meningeal Nerrei are deriveil fmiii the fourth, thu tifth 
(Gasserian ganglion, and fint and thinl divixionx), the twelfth, and 
the carotid plexiu of the sympathetic. 

The Pobteriob Triaxolk ok tiik Xkck. 

[In or«ler tn disiiect the poHterior triangle, tlu; lihu'ltK I>(>ii(>uth tlu; 
head should be removed, and thtf licotl diniwn tlownwanU and to 
the opposite side and secnretl with honlcx. T)i<! Hhnuhlcrs anr to Ik- 
laisea to a convenient heiuht by blockH lieneath tiiir hcu|iu1ic, ami 
the arm drawn down, and ii miEwibltt m-cnivd in tliiit iHwition. Thtt 
side of the neck is thus put fully on the Hiiftch, ana ])riilial>Iy thr 
external jugular vein distended with IiIcmmI will ■«• M'cn liciicatli the 
skin. 

One incision is to be carried fr<ini the liack of the )iiiiiin to the 
daricle near its inner end, and another fiiini iIiIh |Miint alon^' the 
whole length of that lione ; a thinl iuciKioii is t<i )m- nia<le (if neres- 
•aiy) transversely from the pinna to the occijuit, ami the flai> of nkiii 
is then to be reflected backwardn. The diMsertion should Ih- be^un 
at the inferior angle, the dissector of the riijht .side st^tiidiu); by the 
shoulder, and tlie dissector of the left siile at the head, of the 
subject] 

Beneath the skin is the ntprrfirml fu»>-!n, betwwn the loyerx of 
which will be found the platysma. The film-H of this uiiisclc may 
he cleaned at nuce while removing the Hkiii, andean- must U; taken, 
as won as its upper border Ih reached, to kee]> cln.-i! to the xkiii. 
or the superficial nerve* may be injuretl. The suiM-rtii-ial veins aie 
heneith die platysma. 

The Flatynna Myoides (Fi^. !)>(>, 6) Ih only »n-i\ in itH lower 
put, the rest will be found in the dinsectiun of the anterior triangle 
and tmet. It isA^llhputvneous muscle ar!»iwj fmni the fas<;ia over 
the pectoral and deltoid muscles, and very fili(;htly fn>ni the front 
of the clavicle ; it posoeH obliquely acn>s.s the neck to be intrrtfd 
into the lower border of the mandible, and into the lower lip, \,\w 
Ifana of opposite sides interlacing below the NvniphysiK. It i.i 
eefflHed by the facial nerve. Its action is to de]in>Ks the lower Jaw, 
inl it nppean to aid in produchig the cxpreMMonii of grief and tcrmr. 

Throng the platysma will generally Ih- xecn the Sxtemal 
J^^pi]ar ▼•iB (F^. ISO, ij), which runs parallel or nearly so to 



POSTEKIOR TRIANGLE OF KECK. 

the fibres of the muscle ; if, therefore, in bleeding from the jngul«j,_ 
un incision were mode in the direction of the vein, the bIo<«l wouli 
escape with difficulty, iind hence the rule in practice, vii, to rq 
pitrullel to the stemo-mastoid, t. e., across the fibrea of the phttysuu,] 

80 that they may reti-act. 

[The platvstna is to be detached from the clavicle and tani« 
forward, atiu tlie cutaneous nerves ure to l>e sought, some jMUsaiiL, 
iipwai'ds to llic bcalp and cheek, some forwards o\ er the neck. umI 
others ilownwardg to the shoulder and chest. They will l)e foimJ 
to diverye from a point about half-way down the posterior biinler - 
the stenio-mastoid.] 



The Buperfldal BrancheB of the Cervical Plexus art 
arranged in two sets, — an ujiper comprising the Supeiticial Cervica 
Ureal Auricular, and Small Occipital nerves ; and a lower 
descending set, the Sternal, Clavicular, and Acromial liranchcs. 

a. The Superficial Cervical Nerve (Fig. 190, 17) [from the^ 
second and third nerves] will be found turning round the posterio 
border of the steruo-nuistoid, and crossing it trans versely beneatl 
the platysma to ramify over the anterior triangle, where it eoa 
municates with the infra-maxillttrj- branches of the facial nerve, 
supplies the integument of the front and side of the neck. 

b. Tiic Oreat Auricular Nerve (Fig, 190, 1 1 ) [fn)m the secnn 
and thiril nerves] is the largest bnuich of the set, and turning roun 
the jiDSttrior border of the stemo-miwtoid, passes oblii.iuely to 
piniut and ends in three sets of branches, facial to the parotid gk 
and skin covering it, communiciUing deeply with the facial nervnj 
auricular to the buck of the pinna ; and ma»toid to the skin ora 
the mastoid jiroce.ss. 

This last i& often of large size, and may be mistaken for the^ 
following : 

c. The Small Occipital Nerve (Fig. lOi), 3), [fix>m the secon 
or second and third nerves], which is sometimes double, is alwaj 
to be found at the posterior margin of the sterno-mastoid mutclli 
and runs directly upwards to the scalp, where it has been alre.iil)l 
seen. 

The Descending Branches (Fig. 190, 3i), sternal, cUvicoltt, 
and acromial [from the loop between the 3rd and 4th nerves], 1 
the directions indicated by their names, and pa.s.>ing over tb 
clavicle are distributed to the skin upon the upper part of tb 
pectoral muscle and shoulder, where they are seen by the disaecU 
of the arm. 



rOSTERIOB TRIANOLB OF XSCK. 



413 



Tig. ISO. 




Fis. IW. — Suprrflcial diawction of thr tritnrln of the neck (dn«n br 

J. T. Gray). 
I (In nr.iv.r ir. .. .' ii.r i ii;!! i.jii. ,,f iiii- iiii.i.ri,.i iri.i>i.>ie proprrty, tfaf Agum 

tipo»«lbltf tu tM thfi ftub- 



Stii 



of digiitrir and 



, 0«-i|iili>l mWri ud fn»X ocd|iital 

nerre. 
, PlatyuuH ' - 
, InU'rnkl 

tfittbiP'vr'.' 



-iric 



orjr nerve. 

I cm iral imm. 
fOgrtl aerre. 



iy, Lprnlur nnguli Kapiilu'. 

20. Inferior cmistrii^lor of the 

|i)iiirviit. 

21. DpsmiOing brunohr* of thv lupvr* 

ti<'iiil (M'rvif'iit iilrjciu. 

22. ComniMti rarntid nrtory with 

driti't'ndcnt hV|)ob-Ii»ki nurvr, 

23. Sral. • • , ■ ■ 'ill.. 

24. Am 
26. TiTi. 

26. St.T li)i.iU. 

27. Tnipfiiiu. 

28. Strn: ■■' 

29. Po-i fomo-hTold. 
30 Kul.. . .v. 
31. Suiir.i-«i i»imliir artery (tranjiTcr- 

•uli* Inimrri). 
:I2. nmt-hial pUvtus pnrtly corercd by 
onii>-hvi>iil, 




[The anterior and posterior boumlaries of the triiingle (the i 
laastiiid and trapezius) arc now tu be defined, but only the ei 
the musclea need be cleaned. The descending nerves l>ein;j; d< 
and turned >ip, the deep branches of the cervical plexus and tbe 
spinul-aecessory nen'e j>u.~siiij' obliiiiiely between tlie Ixirilera of the 
Kleino-niastoid and the trapezius are to be directed out, iiud il») 
tlie omo-hyoid must-le, which will be found runuiu'^ downwunii 
and outwards at a variable distance aliove the clavicle ; the extern """ 
jujjular vein is to be followed ii-s hu' as convenient, and nuuiirtij 
lai^e veins, which form a plexus at the lower part of the trmMj^lt 
and communicate freely with the external ju;^ular, ure to be uotio 
Tlie deep cervical fascia will be $een and partially reiiiovetl in 
jiroceeding.) 



The Superficial Portion of the Deep Cervical Fascia, whidi 
is very iletise, coinmenccu at the spinous procejtses of the vcrt<bne 
an<l encloses the trapezius luustile, then crosses the posterior triaiigk, 
Hplit;!! in front to enclojM! the sterno-inii^toid, and is continued an I 
the median line of the neck. At the lower part of the poeteria 
triangle it ^ives a special coverin;^ to the omo-hyoid muscle, and id 
attached below to the back of the clavicle and first rib: in 
anterior triangle it i.s attached to the byoid bone, investa 
digastricus and stylo-hyoid muscles, ensheaths the subniaxill 
gland, and becomes connected with the inferior maxilla and styloij 
jiroc.ess and ixiaches the adjacent parts of the base of the elcuILl 
Deeper layers <jf fa-suia cover the deep muscles nnd other structnretj 
of the neck, form a kind of capsule for the thyroid IxkIv, and 
prolonged into iht; tlim-ax and axitlox These, with the o«roU 
oheath, and certidn areolar interspaces (pre-visceral, retri>-visct't»lj 
and slenio-uiastoid tissurets) between the lamime of the deep im 
aie described on p. 436. 

[To see the floor of the triangle the rest of this pait of the Jeep 
fascia is to be removed ; it will be most readily detached by be- 
ginning above at the junction uf the stenio-mastoid and trapezius, 
and carrying the knife obli(|uely downwards and backwaiils su tu to 
l«f parallel to the fibres of the muscles beneath. It should 1* re- 
moved only as low as the omo-hyoid at present, and all branches u( 
nerve and artery should Ik; carefully preserved.] 



The Posterior Triangle ( Fig. 1 !)0) is the space bounded in/wnl 
by the Ktcmo-masloid, liehiuil by the trapezius, ami btlov by Iht 
middle third of the clavicle, its apex being represented by iht 
meeting of the anterior and posterior boundaries at the occiput 
It is covered in by likin, superficial and deep fascisB, aupeifcitJ 



riiSTKItlOR TRIANOLE OK NKCK. 



41.= 



bruiii li .-li. una ("I Ujc ctnicjil plexiio, Htid at the lower purl 

by th' It* jlutn' i» fomirij from ubove downwiinls by tlio 

»I i:iU^ (t;), Icvntor aiifi^iili Huipiil/u (19) (beneath which Hm 

tl .-. colli), kcalc.iiiu iiiMliiiR, M'lilvniix jionticiis (23), iwiil thi< 

Fiv. m - "-'' 



XP^AA^' 




xi\f\mt (Ugtiiaioii of thi) Dumitu* niugniis. The liut cauiiot b« mvii 
at i»ri'«i-iil. 

7*br iplcuius culli d'jVK nut ftmii iHirt uf tho Hoor, bvcaiuu it i* 
covensd iii by the levator unguli wjijiiiliu. In mmc labjocU, whurv 



¥i%. 191.— UiUrel »iow of Uir miuirl 


'« (if tlip pri'vurliibnil rngiuu mid lida 


of thr iippk (f 


■"111 Wil»on). 




1'.'. .S|>I<rlliu>. 


IMjrul Imllr. 


13. ('oniplriin. 




H. Cut «]«« of tlu) trapeiiiu. 


' 4IIC. 


Ifi. Hlimii!Kjid»'U»i itiiiiur. 


!.eM»puU 


111. S. ri ■ • . ii( (uporior. 


pro(«iif. 


17. S.,; 




IH. TIm 


.iwlr, 


Iff. tl'^>|>hit{£uft olid tr>ti'hca. 


lU. 


20. Inriiriuri'iiiutrii'liiruftttrpbiirynii 


111. 


21. Middle rniKtrirlor. 


.. UB. 


22. Superior conitricCor. 1 



K'Ji/ttlJjr, 



416 



POSTERIOR TRIANOLK OF NECK. 



the upcx of the triaD^le is wider than usual, a portioD of th^ < 
plexus may be seen, ami not unfit^iiuently, where the uttacbiiienl 
the gtemo-mastoiJ to the clavicle is not well develoj»erI, lioth 
anterior scfllenus and the plirenic nerve lying on it appear in 
posterior space. 

The triangle is subdividetl into two lesser tnatigle* by 

■ posterior lielly of the onio-hyoid muscle, at a variable distance ab 

'the clavicle. 

The upper or occipital triatigh- contains thesuperficial branches oft 
cervical jilexus deriveil fi-om tlie Hrstfour cervical nerve* ; thenpii 
accessory ner\'e (which may be lrac*d from the level of the traiMvetw 
process of the atlas along the outer surlacc of the levator angn 
Bcajiulo! into the trapezius, where it communicates with brunche 
the 3rd and 4th cervical nerves) ; muscular branches of the ccrvu 
plexus to the levator an^^iili scapultt, scalenus medius and tnipeziq 
^ommunicatingbraIlclle^ with the .-pinul uccensory j theocoipit.il arleij 
the transvewe cerviail ve.sscls, the posterior internal jugular veiij 
the'iipper conls of the brachial plexus, and some of the lynipl 
ylaiula placed along the posterior border of the sterno-mastoid. 

The hirer or mprn-clin-icntitr IriaufiU contains the ciinl* of 
brachial plexus and their feupru-chiviculur Imiuciies ; the tliird ]u 
of the subclaviiin artery ; the nerve to the subclavius ; the tma 
verse cervical vessels ; the supra-scapular vessels and nerve ; a(| 
the external jugular vein, with its lower tributaries ; all of wLid 
must now be dissected. The size of this space varies with the lev^ 
at which the omo-hyoid crosses the neck, with the extent 
clavicular attachment of the stcrno-ma'^toid. and, more impoTtantl]| 
with the degree of elevation of the clavicle. 

[The process of dee]> fascia bimling down the tendon of thi' ••nid 
hyoid is to be traced to its attachment below, and then corefuU 
removed. The external jugular vein, the transverse cervical 
supra-scajiular arteries anil veins, ami the 8ii]ira-.«capiilar ncrre i 
then to be carefully di>sected and preserved. The last will 
found behind the clavicle, and the small nerve to the subclaviiw ivA 
the brachial plexus munt also be Sfrtight ns it passes downwunis m'j 
tlie subclavian lulery. A process of deep fascia connected with th 
scalenus anticus binils down the subclavian artery, and mtm 
removed to exjKise it.] 

The tendon of the Omo-hyoid Huscle (Fig. 1 90, 29) it ' 
down to the back of the clavicle and to the first ril) by a ptiKeas 1 
the deep cervical fascia, so that either belly of the muscle inav act J 
from this fixed point. I'lxin the back of the tendon may be ijiiit^d 
a branch of the communicans cetvitia nerve, which supplies liie . 




THE SUBCLAVIAN ABTERY. 417 

posterior belly. The origin and insertion of the muscle are foand 
in other dixectiona. 

The 'CrmoKrarm Caracal Artery (Fig. 190, 25) is generally 
found at the level of the tendon of the oiiio-hyoid, ami thv Vein a 
little above it, so that their relations to the Hubdi visions of the 
triangle are somewhat different. 

The artery, a branch of the thyroid axis [«ul)clavian], passes 
tnmsversely under the stemo-mastoid and over the sculeue niUHcles, 
aaasea the posterior triangle, and divides niidur the bonier of 
the trapezius into the superticiol cen'icul nud i>ost«rior scapidar 
nteriea. The $itperfieial cervical goes to the tru|K-zius, the anterior 
bolder of which it supplies, and tenuinatvs by anaxtomosing with 
superficial branches of the princeiM cervicis of tlie oecipitsil ; the 
poittrior teapular runs beneath tlie levator auguli HCiipuliu muscle to 
the vertebral border of the scapula, when; it is seen in tlii' diiisec- 
tion of the back. The posterior sca])ular artery, liowever, oftt-n ariser- 
as a separate trunk from the secoml or third part of the subclavian 
srtety, the superficial cervical then alone iiccu]>ying the position of 
the transverse cervical. The transverse cervictd n-in Hex above the 
level of the artery, and usually joins the cxteniul jugular. 

The Snpra-soapular Artery and Vein (Fig. 1!)(), 31) lie 
dose behind the clavicle. The arter}' is nearly always u branch of 
the thyroid axis, but rxxasionally arisi-M from tltc m<cond or third 
part of the subclavian. It runs in front of the thinl stage of the 
sabdavian artery, and passes Whind the clavicle to reach tlie up])er 
bolder of the sca]iula. Tlie ri'in o|h:iii* into the t-xternal jugular, 
just before it joins the subclavian vein. 

The Third portion of the Bubolavian Artery (Fig. l!)i), 30) 

extends from the outer liordcr of the anterior xciilcnuK, oblii^ucly 

downwards and outwards liehiml the clavicle, to the outt^r lionler of 

tlie first rib, where it becomes the axillary artery. It has in front the 

flciiij platysmo, superficial nerves, deep fasi-ia, clavicle, suU-hivius 

mosdie, and supra-scapular vessels ; and i.s cmsscMl by the small ner\'e 

to the subclsvius, and by the external jugular vein, which is joincMl 

St this point by the supra-scapular and tnuisvei'sc curviuil veins. 

BAuid are the scalenus medius and the pleunu Almiv run the corils 

of the brachial plexus; and Mmr, at some distance and in lui anterior 

dane, is the subclaviim vein. The subclavian groove on the first rib 

lies behind and beloic the artery owing t<i the downward slope of the 

lib, and a baisa will often l>e foun4l between the bone and the 

ttmeL In a little more than luilf of the cases this jiortion gives 

off 00 bnmeh, but should there \>e one it will ])robiibly be the 

posterior scapular artery, more rarely the supra-scapvilar. 

K K V. 



418 



POSTERIOR TRIANGLE OF NECK. 



Surgery. — The position, relations and direction of the tbii 
portion ol tli« Mjliclavian should be especiully noticeil. l>t\-an»*l 
w here tliat a ligutun- is most frequently njiplied for aneurir 
lower down. The student shoidd iiartieulaily iiccustom his fisfl 
to feel for the scalene tubeicle on the first rib and the i)utj;r Nf 
of the scalenus anticut* muscle, which arc tnken as the guides Ut 
tOMimencement of tlie third stage of the artery. It shouLl 
noticed liuw materially tlic lelulions of the vessel are ulterwl 
ruiHing or dei)re»sing the shoulder, as tlie efTett of on ujienriani I 
the axilla is to iiiine the clavicl« considerably, and thus to cotuplicaH 
the operation. 

Tile operation of tying the subclavian in its tliinl part in thfl 
performed. The heaif being thrown back and tlie shoulder dcpn 
us much OS possible, the skin of the lower part of the triangle i>( 
be drawn down upon the clavicle, and a lunated incision car 
from the edge of the trapezius to the gtemo-ma?toid, cutting at i 
on to the bone. The skin being then allowed to resume its uatna 
jKisiliiin, tlie incinioii will be immediately above the clavicle, 
may be deepened at the anterior part. The external jiigiihir vein I 
to be carefully guai-ded, and hehl a.side if neces.<ivry, and a cantig 
dissectiim made until the tinger can feel the scalenus aiiticii» 
the tubercle on tlie first rib, to which it is attached. Immediatij 
behind this will be found the aitcry, ami even in the uninjecU 
slate it will be readily recognised by its it)lliug on ih. 1. 
Iieiieath the finger. The aneurism needle shoiiUI be i 
itlx/ve, so as to avoid the brachial nerves, which are moiv , 
included in the ligature than the vein, since this is quite lielow 
artery ; and great care must be taken to avoid injury to the pleu 
behind the iimennost portion of this stage of the vesaeL 

[If the dissection of the axilla is sufficiently advanced, the 
clavicle slioidd now be divided ut the outer border of the sti-m"- 
inastoid, and again at tlie edge of the trapezius. The knif.' 
then passed carefully beneath and close to the lK)ne to del 
subclaviuH, the piece may be removed, but the parts will 
retained in jiosition by the miude. The supra-scapular arr 
vein will now also be better seen, and con be thoroughly l! 
The su)x;laviu8 muscle is to be divided close to the tnipeziu- 
the scapula will fall back, ajid the brachial pleiu.s will In- .u... 
expo.<e(l and should lie carefully cleaned. The upper digitatioa of 
the serratus mugnus, which was mentioned aa forming part of 
Uoor of the subclavian triangle, it also visible.] 



The Brachial Plexus (Fig. 192) ia formed by the onttttor 
divisions of the 5lh, Cth, 7th, and 8th cervical ner\-e« and }i«rt ( 
tlie 1st dorsal nerve, with a Miiall branch of comniunicatiou 
the lowest cord of the cervical plexus (4th). The uervca ap 
(It tlie outer border of the aatemv ataleuu* as four conlt, 1 




' and 8 posterior branch ; the anterior brauches of the 
ililJli: trunks fonn the oul«r cor»l, the anterior branch of 
|u» the inner cord, and the three i»<«terior branches 
the jiosterior cord. Sevcrul varieties have been 
arrangement of the eonls ; but ihU will be found 
'I minion. 

-OiigTwm of the bnicliial plexiu (N(l«r Lucu). 

K K 2 



420 



THE ORBIT. 



The hraiu-he* aftoir the dat-ieU (Fig. 192) — 

o, TLe ntTve to tlir. iiiMat'im is a sruiill bmnch Ijinjf in tnal 
of the plexus, aiul derived from the trunk foniieil l>v the 5th imi 
6th nerves above the supra-scapular nerve. It cionswai the 3rd 4t<pi 
of tlie subclavian artery to reach the muscle, aod comtnunicatea with 
the phrenic nerve. 

6, The ntrve to the rhomboiiU ia from the 6th nerve. It pie 
the scalenus medius, passes 1>«ncath the levator aiigiili soipnhe, 1 
which it gives a branch, and ends by entering the under surface! 
the rhomboids. 

c. The Siiprarseapviar nerve, the largest branch above 
clavicle, apjieai's above and iit the outer side of the plexus, 
is given olf from the cord foniiwl by the 5tli aud fith, or 5d 
6th and 7th nerves.. It disappears behind the trsij^iezius, cLivid 
and jjosterior belly of the omo-hyoid, to reach the »uj>ni-scapu 
notch. 

d. The nerx'e to the- gerratiu nuuintu (posterior thoracic, eit«ni*l 
respiratoiy of Bell) lies behind the plexus aguin.st the semtot 
mognus muBclc, aud is derived from the &Ui luid Cth (and 
from the 7th) nerv'ea liefore they join, the formative bruid 
uniting in the sc&lenus meilius. 

c, A Ijraiirh to the phrenic nerve, of very variable sixe, is given I 
the 51h nervi' at the iipi>er part 

/. Small 1/niHi:h(« to the kmijm colli and »eaUiii mu^'Ies ailM I 
the nerves close to the foramina. 

[If the lime for turning the subject has not arrived when both tti 
posterior triangles uf the neck are dis.eected, the oibit slinuld V* «l 
once j)roceede<l with ; but if not now dissected, this had better " 
postponed until afti-r the dissection of the anterior triangle.] 



The Orbit. 

[The head being i«ised to a convenient heiglit, the saw is to 
be applied to the edge of the skull close to the suin-rior i' 
and inferior external angles of the orbit (the pi-oper jMjint- 
readily ascertained with the finger), and Uie cuts carric 
the orbit. With tiie chisel these inoiMons are to lie pi! 
liackwards till they meet at the sphenoidal fissure, whtu 
portinn of bone comprising the roof and outer wall of the nrUt 
can lie readily tilted furwaixi by a blow with the hiimmtT. 
small remniiut of Ixme can be removetl so as ti> eximse the 
but the margin of the optic foramen shouM lie leli uu 
The dissection for the lenticular gangUon should be cai 
iuter by dividing and lefteclin^ V\\e e'!iL\*xi\a.l vtctu* and 





THE LACRTStA.L NEKVE. 421 

are* from the outer side. Any attempt to demonatiate 
icb«a by the otdinaiy diaaection from above is likely to 

it thing exposed on opening the orbit ia the Faiiostanm, 
letaehed from the Imne. It will be seen to be cnntinuoua 
Inia mater of the hIcuII through the sphenoidal fissure and 
bramen. At the border of the orbit it splits into two 
le, continuous around the margin with the external peri- 
the skull, and the other, forming the superior and inferior 
ligaments connecting the eyelids with the bone. 

riosteum being divided in the centre and carefully turned 
some soft fat removed, three nerves and two arteries are 
Dto view — the frontal nerve [5th] with the mpra-othUal 
the centre, the laerymal nerve and artery on the outer side, 
ittle fourik nerve on the inner side ; the laerymal gland is 
It the upper and outer part of the front of the orbit.] 

>tirih Vwrra (Fig. 193, 13) (trodiUarit or paihttitiu) has 
ien traced through the cavernous sinus to the sphenoidal 
here it occupies the highest position, and is now seen 
I the inner side of the orbit to enter die superior oblii^ue 
ose to the edge of its orbital surface ; this arrangement 
bom that of the other muscles of the orbit, which are 
m their ocular surfaces. 

tontal ITerve (Fig. 19.3, 8) [6th], the largest nerve 
through the sphenoitlal ftssure, lies in the centre of the 
I divides at its posterior part into $tipra-orbital and 
Uear branches ; the«e turn round the margin of the orbit 
rehead, the supra-orbital usually breaking up into two 
before emerging, the outer and larger of which escapes at the 
ital notch, the inner through the shallow groove of Henle 
«rial side of the notch. The supra-orbital supplies the 
did, the diploS, and the frontal sinus ; then pierces the 
md is distributed over the scalp nearly as far as the 
mture. The supra-tn>chlear passes out at the internal 
logle of the orbit, and supplies the frontal integument 
Iw median line. 

mrymal ITerve (Fig. 193, 13) [6th] lies on the outer 
» orbit and passes to the laerymal gland, which it supplies, 
k twig to join the orbital branch of the superior maxillary 
id finally perforates the palpebral ligament and is dis- 
twtt the outer part of the upper eyelid. 



422 



THE ORBIT. 



The Bupra-Orbital Artery (Fig. 1«4, 8) is a branch of I 
ojihlhalniic iirtery, and accmiifianies the iiupra-orbital nen'c to 
forehead. The supni-orbital and 8upra-trochlear veins fotJH tk 
bonimeiicenient of the facial vein. 

Fig. 193. 




The Lacrymal Artery (Fig. 194, is) ia a gnialler broocii ak^^ 
from the ophthaliiiic, and sup]ilies the lacryinal gland. It is joina 
by twigs from tlie middle mcningejil, and sends some anuxll lirunc 
to the eyelids, and others through the temporal bone to the teinp 
fossa. 

The Iiaorymal Qland (Fig. 19-1, 4) is about the tite 




Fig. 163. — Superficial duccrtion of tlie nerve* of the orbit (from llirachfbM Uk-tf 

Leveille). 

1. Inner (lirision of Bupm-orbital 8. Frontal nerve (5th). 



none. 

2. Outer ilivition of supra-orbitil 

ncrie. 

3. Supra-trochlear ucn'c. 

4. Lucr)mal itliind. 

6. Infra-lroi liloar nerve. 

0. I.evator palprbrae luiH^rioria. 

7. Sanal nene (Stb). 



6. Second ner^'e, witli iott 
nirotid nrtery oa itA inner « 

10. Rectus superior. 

11. Third niTVe. 
1'2. Lucrvijiiil nerve. 

13. Fourth nerve ou juperior obUnw. 

14. Gaaaeriiui ganglion of Bfth. 

15. Sixth nerve. 




THE OBLIQUUS SUPERIOR. 



4S3 



ikU atiuond, of u ixildiili-lirowu cciloiir, aud ix Kituatcil 
r nnil ouUt jinrt of the orlnl. It in iiouvox mi it» 
t, to At intn ihi- liu-rymal fo&'ia in tlic (irl)ittil plate 
jOBtal bone ; (nni ooncavo lioiiefltli, wbrru it U pliiced over 
[klL lu (luctn, mivon or eight in number, urry the u-cre- 
t t«ani, to the «ur&ce 

bnjunctiva iN-nrath Uie ^Us- IW. 

(1 o( tba upper eyelid. 

frontal ni-rrc i» to Ijo 
and a book inarrti-d 

the 

:.|.:h; 
fu'le iimi llic ><ii|ii'riiii 
lire thi'ti til li<i clriini'd, 
(y taken not to flc»trov 
W pu Uny thrtiiigh wliick 
feHt the latter works. ] 

' ObUquoa Superior 
i'J, 2), the most KupiT- 
lacle of the orbit, urita 
p upper niiu^lu cil' the 
vncn, above and h little 
liter aide of the levator 
t, Ita belly riina along 
trior internal an^le of 
i, aiid ends in 11 round t«ndon which ptuue* throtijth the 
U pulley-like rinj; of tibrou» tisfiiie iitlachrti to the tr"M;lile.ir 
, ou the forcixirt of the orbitid Mirfuce i<( the froiilul iMjne, 
uptly dowtiwiirdx, lutckwiiriU and outwiinlH to th« 
tendon exiJiiuiU near it« iiurrtion, unil jHUuiea 
Bperior rectux to be attached to the outer »ido of tlte 





and rslni of the orbit (from IIinchf«ld and LerrilU). 



{ue ten Jim. 

■---'• frwm 

riTt'il, 




!). Ciliary iirtcfir«. 

10. OpIitliHlinii' nHii. 

11, Urtgin* ul' oblii|Uti» miptirior, 

l»iraltir {lalpnbru', nnd •uperiar 
ret'tm. 
13, [.aery null itrtor)'. 

13, Optii' niirve. 

14. llphthnlmio nrtery. 
16, C.irotiil artery. 
16. Caverooua •inua, 




424 THE ORBIT. 

posterior half of t}ie eye-bull, between the sujierior and the i 
recti. With « little di.ssection a delicate synovial membmne c<ii Ur 
seen, lubricating the tendon where it passes through the troMai. 
Tlie muscle is giipplied I'V the 4tli ner\-e on it« orbital a*iiect. Iti 
aetiim is to tuni the pupil downwarils and oiitwiuxU, and to roUbe 
internally the upper extremity of the vertical meridian of the 
gliilje.* Its tendon is inve8te<l by a process of the cajMole of 
Tenon, but not its muscular belly. 
^V" The Levator Palpobrse Buperiorls (Fig. 199, i ) arim hj • 
small tendon from the upper niai-gin of the oplic foramen, below 
kthe origin of the nuperior oblique ; it expands in front to be ixjrrtnf 
ilnto the convex border of the tarsal cartilage of the upper eyeli 
Its tendon contains a large quantity of involuntary niuscular lib 
^and gives delicate slijis to the inferior ]>alpebral ligament anil sik 
of the uiij)er eyelid. As its name denotes, it is an elevator of tb 
upper lid ; and in this action it is assisted slightly by the snperia 
rectus and occipito-frontalis. It is sujyplied by the upper division ( 
the 3rd nerve. 

[Till' hook is to l>e removed from the eyelid and fixed into tb 
ciinjiuiitivn, which is to lie drawn gently forwards ; the levaio 
paljiebroj is to be cut, and the little branch of the 3rd nerve tr 
to it. The superior rectus, which is then seen, should be cleaned.] { 

«•' The Rectus Superior (Fiy. 199, 3) arises from the mai)pn of 
^ tlie o])tic lui-amen, below the origin of the levator palfiebnp; and 
is instrted into the sclerotic coat of the cyeliall at its upper and 
' anterior part, giving also a small slip to the ujiper part eA the 
..''tareal cartilage. It is gupplicd by the upper division of the 3rii 
jberve, which can be seen entering its undcr-surface when I'l 
muscle is divideil. Its oition is to elevate and adduct the nii. 
and til rotate inwards the vertical meridian, and it aids the Itvui.u 
puljiebroj in raising the upper lid. Like the rest of the mu.- Ii« 
of the globe it is invested by a closely adherent proctsss of the 
capsule of Tenon (see p. 431). 

[The rectus having l>een divided, a quantity of fat will lie brou^lii 
into view, ttiTOugh wliich the optic nerve pjsses to the eyelmll. TLe 
nasal branch of the 5th is at once to be looketl for cros;>ing the optic 
nerve fram without inwards, and the lenticular ganglion, a mioutr 

• Tho ' vertical iiipridian ' ia nn imairinRrv pl.inc biacftint; the globe prrpti- 
difularly in an utitero-posterior dircttion through tlie middle of tlie eoniMUil 
rotitrul point of the oyc. lintation ■ inwards' or ' outward-s ' of the inrridiiiu n*ii 
to the ujiper extremity of tliis [ilune. 



»f" 



THE NA.SAL NERVE. 



425 



' Ml tlir (iiiUT »iiU< of tlio fiiitii" nerve near 
1. ing lia<:k »<->mi- of tb* »miill f.iUnri) jiorvtw 
nuitid the: ojitie ncrvi', ninl mnuc of wliiili 
It will bf liftliT Been friim tho mitiT 
•iiri r oiv]-i.iri I'l iiif extfriiul reclux. All l>niuchi'ii of llm 
opJithiilmtc artery ahouKl W jirvwrved.] 

Tbe STasal Nerve (Figa. 103, 7, ami I US, 9), [0th] ent«rs the 
Fig. IM. 




1 ?i i 



irrUl Wtwceu the huttls of thv pxtenial rovtoa, aiitl then crosaes 

above thi" ojitic nerve ami internal ructun ftum without inwiirJa, 

tn jv>M tbroii^h the anterior i-lhiunidul furunum iinil re-enter the 

:m. Thi-nce it runs into the uo*e through u slit by the siile of 

t.-rinr jiiiTt of tlie crista Kulli of the uthnioid hone, to aiipear 

"n the fn-e hetwicn Ihc noaal hone mid the mii»'rior 

d cArtihij.1'. It givwoH', 1, tho imi/ rool to tha leuticukr 



Fit. 195.— ^'^^•o of the orbit, Men ttam the outar «!ile (fyom ITinchfelil uiil 

LeroiU*). 




TbinlnrrTv. 

Naaal orrrc, glrins olf a long 
piliary nvrrti in tlir urlnt, and 

•■rig ro^'t ^'f thi- IfTiticulur 
I Urfuio rutclinic tllP 
i.ft.it. 
k. SiiUj niTTc. 

Tniril, (>r '/iilillijlniu: ui-ivc (Sth). 
•in 

ual rectiu. 
1.1 ' • 'tho long wut 

; mr gnnglion. 



9. Branrli of third nerrr to levator 
palpebnu supenotu Nnil miiw- 
rior rertiw, 

10, Inferiur rocliw. 

tl. lluok iilat-iij on •iiperior rvctua. 

1'2. Bniiicli iif lliiril nerve to obUquua 
inferior. 

13. Frontal nrrvo (cut). 

14. Kyebnll. 
lo. Snort eiliur^ nervv. 
tli. Inferior nbhiiite, 
17. UuMrian ganglion. 




42G 



THE ORBIT, 




ganglion, on the outer side of the optic nerve ; 2, two fonir < 
ntrre», which rim with the short ciliary hninches unil jwrforat* i 
ilerotic near the entrance of the optic nerve ; 3, the in/ra-iroMar 

iY, which, arising ju«t before the nerve enters the cUimotiUl 
fonuucn, jwsses forwanls to escape from the orhit lieneoth 
pulley of the superior ohlicjue. It communicates with the -njir 
tnx'hlear nerve, and is distributed to the integument of the eyelid 
and side of the nose, the lacrimal «nc, the conjunctiva, and 
caruncula Incrynmlis. 

The Ijenticvilar O-anglion (e.Hiary or ophlhalniie) (Fig. 198) i 
a minute pink bixly placed between the optic nerve siul ext 



Fig. 196. 




rectus near the back of llie orbit. It should l)e exposed, i 
mentioned, l)y division of the external rectus after the remd 
the outer wall of the orbit. It has, like all the cranial gangU 
sensory, inoUir, and sjTupathetic roots. The teruory or long 
(z) is derived from the nasal branch of the 5th, and enters the 
terior superior angle of the ganglion. The motor or short root i 
is derived from the brunch of the 3rd nerve supplying the infei 
oblique, which can be seen p.'issing along the bottom of the orhili 
this root enlera the ganglion at its posterior inferior angle. 
»\imjHilhflu root (6) conies from the cavernous plexus on t| 
internal carotid artery, and enters the orbit through the sphenoid 
fissure ; it joins the ganglion lietweeu the other two root», but c<a 
rarely be seen in an ordtnar)' dissection. 

The aliort rUiarij hrnurliti of the ganglion arise from its upper ; 
lower angles in front, and are eight or ten in number. They pierwl 
the back of the sclerotic coat of the eyeball around the optic sem. 



Vi%. 196. — Dingnuu of the lenticular g&ngUou (fh)m Hinehfeld soil liaraSi), 

I. Lvntirular ganglion. 6. Bympnthetia root from 

{ilexus. 



2. Long root from — 

3. Niual branch of fifth. 

4. Short root from — 

6. Kurre to inferior oblique. 



7. Short ciliary ncrrcs. 

8. Long ciliary nerves. 



THE OPHTHALMIC ARTERY, 



427 



■nA tnnning between the choroid and sclerotic wiili llic long <uli«ry 
ncrv«s 8uji|dy the irig, tlit> ciliurj' muscle, and the coruca. 

Tlic Ophthalmic Artery (Fig. l!'7, 2) ariM.-« from tlie iutunial 
cuotiil doee to the nnt«rior clinoid proceiM, and ontr.rs the urbit 



Fig. 197. 




thTuiiKh the oplic foramen with Iho uplic nerve, but h> il» oate* 
«ide. It gives off the fullowinf! bninchu* : — 

a. Tlic Lacrymal tirUry(^) acc(jiu])aiiies the lucrymal nerve along 
the external miperior angle of tliir orbit to the hutryninl gliuid, 
yrhi' - '"■*■ It jnvei twi({ii to the conjiinotiva and eyelidH, 

«Bil nfsh nmnU foraininii t"i reach the tvniiHiral fiwad. It 

U joiu«Hl by a : thi- inidijle meniiijjenl. 

ttk. Tht Siij-i' 'rry ( 1 1 ) a^ceiiiU to join the frontal nerve, 

•nd oflenronls accnnipimieH the nupra-orbitttl nerve throii(,'h the 
•opm-orbitAl notcli to the forehead. 
e. Mtiteutar brandies (4) ore given to uU the raiudea of Uie orbit, 
<ntering them on their ortUar surfaces. 
d. The Ciiiarii />nitu-A«> (Fig. 1 li8) are nutneMUs small arteries 

Vif. 107. — Arlerie* of the arhil from lb' out«r aide (from Ilimbfeld 
and Leveillii). 



Inlrniiil rHrolTiI. 

A: 






■ Mil m*s. 
.rtery. 

■ rv. 

iiinvdiUI artery. 

■ii'f. 



9. Anterior Hihtnoiilil artery. 

10. Ubliquu* inferior. 

11. Supru-urliiliil artery, 

12. Fi. ' - - 

13. 1 

14. i'. ri««. 
14. N..-. V. 




11 - 




Fig. 198. — SrJieme of ciKulatiun in eye (aftor Leber). 

1. Conjunctival resaeU. 

2. Sinua circului Teuosua. 

3. AnU'rior ciliiuy iirtfn'. 

4. Greater nrteriiil rircif of iris. 

5. Recurrent branch of cntcrior 

ciliary iirt«ry. 

6. Iris. 

7. Muscularnndronjunctivnl vessel*. 
7«. j\rttTy to c'iliarv nrocfs«-s. 

8. Leaf. 



9, Chorio-capillorui. 

10. Ciliary plexus. 

11. Vena Torticoeo. 
13. Episcleral bmRch of long cili 
lo. Deep branch of long ciliarj-. 
17. Lonff ciliiiry urtery. 
19. Short ciliary artery. 
21. Smaller retinal voMelt. 
23. Central veMels of retina. 




THE OPTIC NERVE. 429 

for the aupply, mainly, of the choroid, ciliaiy jirocesiies, and irie, 
and have been divided into anterior and potltrior, the latter piercing 
the Mletotic near the entrance of the optic nerve, the former usually 
derived from muscular branches perforating the dicrotic cli>se to 
the margin of the cornea. Of the }K)i)terior ciliarj', souie, the 
Aort ciliary (19), break up at once tofonn the arterial plexus of the 
choroid ; others, generally two in number, the luny riliarij ( 1 7), run 
forward between the choroid and nclerotic to join the anterior 
dliaiy in forming the great arterial circle of the iris. A branch 
enters the optic nerve to run in it to the retina, uml i* culled the 
arttria centrali* rttirue (23). 

c The Ethmoidal arteria, anterior (Fig. li>7, 9) and poxteriur (7), 
pass through the ethmoidal foramina in the inner wnll nf the orbit, 
the anterior accompanying the muuil nerve. They xupply meningeal 
twigs, and branches to the nose, the anterior ending mi the face 
and anastomosing with the lateralis nasi. 

/. The Ptilpdiral arteriet, two in number (14), leave the orbit at 
the inner side, to be distributed to the upiH-r an<l lower eyelids. 

g. The Frontal artery (13), one of the terminal branches, turns 
xoand tlie luoixin of the orbit at its inner angle to nvcompuiy the 
raprartrochlear nerve on the forehead. It supplies tlie miiHcles and 
integument and anastomoses with the supra-orbital. 

A. The Xa*al artery ( 1 5), the other terminal bmneh, leaves the 
orbit at the inner side above the tendo oculi, and anastoniimes on 
the side of the nose with the angular branch of the facial artery (12). 
The Ophthalmio Vaina (Fig. li)4, 10) arc fonnetl by tril>u- 
taries which correspond genendly with the branches of the artery 
and form two trunks, a lupervjr, conmiuuicating with the facial 
vein and running through the sphenoidal lis.sure 1)etween the heads 
of the external rectus to end in the covi^nious sinus, and an inferior, 
which either communicates with the pterygoid })lexus thnmgh the 
spheno-maxillory fissure, or terminates by joining the HuiH-.rior, or 
opens separately into the cavernous sinus. The nine rortirwm 
which return the blood from the choroid are four in number. Tliey 
do not run with the ciliary arteries, but ])ierce the sclerotic near the 
equator of the glolic to join the ophthalmic veins. 

The Optio Nerve (Fig. ia4, 13) (2nd) enters by the optic fora- 
men, and pa8i<ing through the centre of the orbit to the eyeludl, 
piercea the back of the sclerotic about ,'„th of an inch to the inner side 
of the axis of the eyelMll to end in the retina. It has u comjdex 
(heath derived from the meninges of the brain. 

[The optic nerve is to Ije divideil, and the globe turned forwards to 
hnng into view the njoscles beneutlj.J 






.«/ 









A>i\c fM'-"'^ . M\ of '■"*=^ ,;,„, ilie ex«« com**'., , 
surface ot ih ^^^ (IV ^^^ V3e\ov^^^_ _»^ 









lienor- 




THE CAPSULE OF TENON. 431 

nuae it xec«ive« communications from the cavernous plexus and 
be nasal nerve. 

The upper divintm (9) has been traced above the optic nerve to the 
erator palpebrte and superior rectus muscles ; the louxr divition (12) 
■ now seen running; beluw tht? optic iier^'e to give small brunches to 
the internal and inferior recti, ami a long branch which runs on the 
inferior rectus to the inferior oblique muscle, and nupplies the short 
root to the lenticular ganglion. The nerve to the inferior obliiiue 
ia the only long muscular nurve in the orbit. 

[To expo<« the obliquus inferior, it will be neci-HSiiry to dniw the 
eyeball to the up]KT and outer angle uf the orbit, iui<l t<i ri-move the 
conjunctiva ut the lower and inner part.] 

, /-••. 
The Obliquua Infisrlor (Fig. 190, 9) uiuxcle licii (ibliiiuely iu;i^^,^ 
the orbit beneath the rectus inferior. It urium from the ll(K)r of ,'...' 
the orbit just outside the lacrynuil groove, and poraing Ixdow the .■ . / 
inferior rectus, then Iwtween the extvniul rvctUK :uiil wlorotic, is 
tnterUd into the globe a little behind the (-(luutor, nbovi- the level 
of the rectus extemus, and close to the iuHvi-tion of the obliquufi 
anperiiir. Like the other muscles, it receives an invi-stnient fi-oni 
the capsule of Tenon. It rotates the upjivr end of the vertical 
meridian of the globe outwards (antogouiKing t)ie .iiiiieriur oblique) 
and aids in abduction and elevation of the comcu. 

Summary of the Aetiimi of the Orular Mum-li:*. — Tlii- wjmcft.in 
naaed by the s uperior r ectus and inferior oblique, d«^m!!<sed by 
the inf erior rect us and BU]<erior obluiue, abducti-d by the exterpal 
r ectus , and add uctetl b y the. intental rectus. The upper end of 
the vertical meridian of the eye is Totate<l outwanls by the inferior 
oblique and inferior rectus, and inwards by the su])crior obli<jue 
and superior rectus. The oblii^ue upward and downward niove- 
menta of the cornea are effected by the same muscles as the direct 
movements, aided by the extenial and interaul recti : thus, the 
eye ia directed upwards and outwards by the conibine<l action of 
the anperior and external recti and the inferior obli(|Uc, down- 
wards and inwards by the superior and internal recti and thi- 
inferior oblique, etc. 

The Capanle of Tenon may be demonstrated upon tlie bu1>- 
ject without any aerious difficulty, and should Ih; carefully studied. 
The capsule proper invests and is co-extensive with the Hclerotic. 
It is attached in front to the margin of the coniea (where it forms 
the ' subconjunctival tissue ' of ophthalmic surgeons) and lH>hind to 
the sheath of the optic nerve. Its inner surface is smooth, and is 
anHuated by a kind of lymph space from the sclerotic, vrlvile 



432 



THE OBBIT. 



its outer Burface is connected with the adipose tissue of the txtbii 
bands of runncctive tissue. 

It is pierced by the vessels, uerves, and muscles of the rve, an 
gives off tix x<a<ji.nal j/roctites, one to each muscle. That lu tie 
superior obli4Ue covers oidy the reHected tendon and termiimtc* u 
the pulley, the others funn each a loose sheath for the tendon, ^l^l 
blend intimately with the jieriniysium of the raiiscuhu Wly ui 
become less and less demonstrable ns they approach the origia 

Fig. 200. 




J 



With each of the vagiival processes, except tliat to the supcnar 
oblique, is connected a jn-ocejw ofjieution which is directly or iuiliwctly 
Attached to the iKiny wall of the orbit in such a manner as to 
the contraction of the muscle and alter somewhat it« line of actiim. 
These secondiuy processes ore of considerable strength and oont»in 
\ui8triped muscular fibre. The external rectus process in attachei 
to the outer mai^in of the orbit, the internal rectus proce*; goes t" 



«tlyy 
rtiiin." 



Fig. 200.— Frontal section of orbit (after Merkel). 



1. Supra-triH,hlear nexvo. 

2. Frontiil nerve. 

3. Lcviilur |iul|iebra!, 

4. Superiiir rertui*. 
.5. Superior <il>liq»p. 

6. Tenip<inil ntiiHck'. 

7. Iiifra-trix'liU'ar nerve. 

8. LacnTnal Kiund. 
P. loteruiil rectus. 



10. Lncrvmal nerve. 

11. Middle turbinate bone. 

12. External rectus. 
Ill, Inferior rcrtuB. 
H. Inferior oblique, 
l-'i. Infumlibuluni. 

IC. Superinr muxUlary nerve. 
18. Antrum. 




THE SIDE OF THE NEC;if. 43.S 

lactymal creiit, while tlune of the xiiporior ami inferior recti 
s to tlie orbital l>onler of the tarttal mrtilii^^'s, iunl only iii<lin>ctly 
the orbital margin throiiKh the tuTMil li^'iiineiits. In ailditiun to 
!W structures, Mr. Lockwosd desiTilx-s a xux/uKX'^n/ hni'l which 
tttacheil to the inner itnil outer wM* of the orliit, niul forni.s n 
ml of hammock pa.iAing lieiieath imd Mujiiiortiii-; the f^lolie. 
If all the contents of the orbit are n-nioveil, the nrhilnl liranrh of 
M iVftrior uwxiUitry niriv {Uiuiiitrn-mnlur) may be neeii i;iv>«in>; 
litough the iipheiio-niaxillary tisHiire, ami iliviilin;; into two 
mnches — the sitlirntunein mnln; whieh jiierfos the niahir iMine. 
ad the UmiioTitl hnmrh, which pieivcs the outer wall of the orbit 
Rach the tenijioral intet^mnent (p. 3!>l) ; ami the spheno- 
lUxilUrr tiiMure will be fuuu<l closed by iuvDluntary niUHi.-ular libre, 
:h« Mtalii. 

TlIK SlUB OF THK Nkl'K. 

[Thelieiwl is to be drawn a.-* far back as iM)«-<ibli" l)y mean-" of a 
houk pWed in th4- chin, anil the side to be ili^'gecti'd (j>y ]ircl'cruncu 
the rii;bt side first) shouM be made jironiinent by nn-ans of lilocks 
liW'ftl Ix'neath. Jlefore bevrinnin^ the dissection, the student should 
nuii hii) tin};er alon<; tin- median line of the neck, and recoi^nise the 
following' points. Kirstly. the lowi-r jaw, and from an inch and a 
half tu two inches Kdow it the sli^^dit ]>r<>je>-ti<)n of tlie hyoid bone ; 
next a hollow, cori'es|M>ndin;{ to the tliyi'o-hyoid mi-nibrane, anil 
below this the projectinj,' anjjle of the thyiiiid cartilage Cjiomiun 
Ailoini], which is very small in women; alsiut an inch Ih-Iow the 
pomuro Adami is a depression corres|K)ndini{ to the crico-tliyroid s|>ace, 
thMOjjh which kryiifjotomy is ]ierformed ; still lower will lie felt the 
iMnIriii;;of the crici>id cartila;,'!-, and in a thin subject the rin^^s of 
the tnclica may be reco^nise<l lower ilown ; sometimes also the 
iithmiiiof the thyroid body may Ije felt crossin;^ the trachea, usually 
Ofcr the iK:c<m<l an<l ihinl rin^s. 

An inciaiou is to be maile fmm the chin to the steninm, ami 
another outwards aloii}; the clavicle as far as the incision iirt-viously 
Bide in the di-sseclion of the ixisterior trian^de, and tli<.- tlaj) i>f 
lUii ii to 1>e diasected up over the fa-'e. Thi^ |ikityaina mav be 
<^mtA in the upper part of the s|Kice at once, and it will fa<-llitate 
til*! o]itration if the jiart detached from the clavicle is held down with 
lioob.] 

The Platysma Myoides (Fi;;. 1 !)0, 6) is now si-i-n to reach to 
he julc of the lower jaw, where it is partially ins»'rte<l, but most of 
* fibres blend with the muscles of the lower li]i. The miiside 
KUHatea in the median line with its fellow of the o]ip(xsite side for 
•hort distance above, but at the lower ]iart of the neck a large 




"-»n'-iit.i\iuun 



Fig. 201.— Diupram of veins of head and neck. Tin- umy! 

cxteninl ju^iiliir sAsteni ia blitt'k, the inUrnnl jtij^uliir »y8te]n in 
oullint*. 



1. Sii|irii-orbitnl. 

2. Antorior U'mporil. 
8. Siiprii-ti-iiclilcar. 
i. >lii1dl« ti'mporiil. 

5. Paliiebml. 

6. TeraponiJ, rcooivint.' tninsvcnw 

fui'iftlf |)iirotiil, tiiiil niiriculnr 
IrihuUini'K, mid jninin); witli 
intrniul mii.viUan (not tliovrti) 
to form l»'in]i<ir<i-iniixi\\iiry. 



7. Lutcnil ti:unl. 
K. OiTipitiil vrin di»ippriirirtt 
rt'acli the deep \ ciat of I 
iieik , 
!i. Siipi-rinr Inbiiil. 
10. roBtorior nuriiular 
U. l*ft'p f:lciill. 
12. I'fu'tcnor extiriiul jiiKUlar. 
I'i. (.'nmtnimtcittiiiir tuiTtjil. 



Ma 




THE ANTERIOR .UOUI.AK VKIN. 435 

A 

interval exiiiU iMtween the two. A few small branches 
erficial cervical nerve will be found piercing the muscle, 
tenud and anterior jugular veinw may Homctimes lie seen 
I fibres. 

itysma is to be carefully rftlected upwanlx like the xkin 
eial nerves are to be di8Mect<>d out, and the Htemo-mastoid 
removing that part of the deep cervical fiuscia which fonus 
cial Liyer of its xheath.] 

rtemal Jogrnlar Vein (Via. 201, 14) in formed l>y the 
' the internal maxillary and tem]><)ral veins in the parotid 
le trunk so formed {ti-mixiro-majfilUirii) is soon joine<l by 
>r auririiliir (10) and sonielimes by the ocripUal vein, and 
laige communicating vessel, the (•ommunicating facial (13) 
Qon trunk of the lingual and facial veins (internal jugular) ; 
jmas the stemo-niastoid 1>etwcen tliiw muscle and the 
ind receives, near the middle of the neck, the po$tarior 
tN{ar(i2) from the cer\-ical and occipital region. Keach- 
iter border of the stemD-mnstoid, close to its clavicular 
joined by three tributarit-H, the tranirtrtalii colli (16) and 
lar (18) on the outer side, and the anterior jiigtilnr (23) 
Finally it pierces the deep fascia and opens into the hu1>- 
0. The vein and its principid tributaries are valved before 
nations. 

torior Jncpilar Vein (Fig. 201, 23) begins lieneath the 
! anion of small superticial and deep branches, and passes 
leck, near the middle line, to reach the stcmo-mastoid. 
dves a tributary (19), sometimes of considerable size, com- 
; with the facial al>ove, and running along the anterior 
he stemo-mastoid. It then pierces the deep fascia, runs 
e stemo-mastoid a little above its origin, and ends, as 
he external jugular. The two anterior jugular veins are 
ither, just above the steniuni, by a transverse branch, 
I in the fat between the two layers of the deep cervical 
e vessel may be wounded in the u]ieration for wry-neck. 



22. Cephalic. 
mU* colli. 23. .interior jugular. 

trank of lingusl und 25. Middle thyroid. 
(Unnal not seen). 27. Vertebral. 

i^mur (should be larger). 29. Inferior thjToid. 
jognlar communicating. 31. Superior intei-roatal, 



ttjy'iiid. 



33. Internal mammary. 

y T a 



436 



THE SIDE OF THK NECK. 



The Superficial Cervical Nerve (Fiir- 1!>0, 17.1, n turrt 
Muall ^izl•, is sei-n to divide into two or three branches snpjjjia 
the skin over the anterior triangle, tlie up|j<:r one coiiiiuuniaitti 
wilh brunches of the facial nerve Imlow the jnw. 

The Sterno-Cleido-Maatoid Huscle ( Fig. 1 90. 28 ) .rrv-i W\ 
roiindrd tendon from tlip anterior .»nrl'iice of the manubrium ste 
about half an inch Ijtluw the sn]iia-sten)al notch, and by a luo 
tenilinotisbilaininar ori^jin from the inner tJiird of the upjier jwrt 1 
the clnviide. Between the two Iieails of orij^in is a ci-lIiilHr intcrva 
which may extend for some dist^ince up the neck. The Bletui 
jiortion of tlie mtiscle is intrrieil into the anterior bonier iuid out« 
surface of the miutoid process of the tunipoml bone {gtono-nifnlmd 
and into the outer half of the superior cnn-ed line of the occipiti 
bone (strrno-ociijiiJiilu). The suiwrlicial lamina of the cUvicttll 
head (chido-mwitoiti) forms a innacular belly, which j^aases ti> 
mastoid process beneath the inaertiou of the sternal lieud ; and tK 
deep lamina (dniUi-dcciyilaUs) runs to the superior cur\i*d line 
the oicipitul bone undenienth the hinder portion of the stifc 
hearl. Alonj,' the posterior border of and bencAlh the niil«c1e wB 
I)e seen several small lymphatic glands. 

The action of the stenio-cleido-niastoid is ( I ) to flex the neck 1 
all the -cervieal ailiculations below the second; (2) to lateraluM I 
hrad towards the shoulder of the same siile, moving' all the cervio 
joints except the second ; and (3) to rotate the face towanU 1 
opposite shoulder, portly thi-ouj^h the allanlo-axial joint, oixl par 
at the other cervical articulations. Thus, during complete 
traction, the face would be made to look upwards and to 
opposite side while the neck is inclined forwanls. If 
muscles act toi^ether from below they would diivctly flex 
neck at the cer\ionl niticulatinus below the seconil, but 
wouhl tend to extenil the head at ihe o<xipilo-atlantal joint, 
the head and neck be fixed the muscle raises the stemmu anil ( 
aids in inspiration. 

The supttrllcial layer of the Deep Cervical Fascia, which I 
been <h»'ribed as extemling from the trapezius across the (>Onter 
triangle, ami then as forming a sheath for the sterno-mastoiil (p. 4 Hi 
is now seen to cover in the parts inclu<Ied in the anterior triaaglc^ 
ami to extend to the median line closing in the carotid and »nb.] 
maxillary triangles (p. 4.'i8). Above it adheres to the body of tlwJ 
hyoid bone and, after ensheathiiig the submaxillary gliind, is ottarWl 
to (he inferior maxilla ; below it is fixed to the upper boi-der of th* J 
sternum, theiv splitting into two laminie, lietween which 
included some fat uiul a tTansvet»e bvanuU unilin<' the two anlenorl 




THE ASTEUIOll TKlAXfil.K. 4:{7 

jugular veiii«. A .SVroMf/, docjwr liiyvr cif fii<riji cuvits tin- stenio- 
livoul, thrrohyoid and oiini-liyijiil, liimliii^ dnwii tin- ci-ntnil ti'iidou 
uf the latter iiiusole tu thu cliivicli:, ami .-ti'iidiii^' :i ]>i'<irfss ciilliMl tlu- 
MrJinntinum c>lli Itackwanls l>«t\v«.'»-ii tlu- i-crviwil vi«riTii (n-snpha- 
ffU, Ltrynx and tr.ichuii, ki:) ami tin- (.'niiiiiinn caiotiil arlcry, t» join 
the ptvvertuUr.il uixiiieiimsU o|i|HiMt<- tin- riTvicjil tMiisvi-isf \>n>- 
cesses. A Tliint and still iI<-i-]hm- layi-r cnsliratlis tin- tliyniiil IhhIv, 
fixejt its UthniUH ti> thu hyoid lionc, ;ui<l it-i lat<-i'al IuIh-.i t<i tliu 
cxtmuitieif of tlu- tir.»t and wcond tracliral i-in>;s ifitfirrinr nml 
laternl thyruiil liijiiminlti) : and imssin;; diiwinviinls lu-i'iiini-i ton 
nected witli the fiirtit of the ]icri>-ai'<liiini. Tin- niinliil JlhIIi in 
formed liv the junction of the various hiy<-rs of riMvioal fascia sur- 
rounding the veiMclx. 

Well niarkeil lynqili sjxives may l>e di-iiinnstrati-d ln'twt-on the 
faflt'ial layers* in the neck in certain situations. Th<- <'lii<-f of these 
an? (1) the jtrf-riiu-i rill Jitisitri, in front of the traiiica and thyroid 
body, extendini; downwanls hi-hind the lower i-MiiMiiifii-s of the 
riterno-hyoid and st4.'mo-thyn>id muscles into ihe sujierior nieili- 
HStinum ; (2; the rrlrn-rionrnl jinnnr-, liilweeii the jiliarynx and 
cei;oi>liagUi( in fnmt and the vertehral <'oliiniii anil pre-verteliral 
muDcles liehind. This is Ixiunded on each si<le liy ihe iiii<liiiiiiiiiiiii 
milt, and may he traced ahove as far as lln- liasi- of tin- cranium 
and dovnwards into the sujx-rior and ]io>lerior nieilia<tliia ; (3) the 
Aerno-madoiil finurr, liehind the lower jiait of the stermMiiastoid 
muiicle. It extendi) downwards into the axilla anil into the su|ierior 
inediastinuni. Tliese fissuivs have considi-raMe inlliience ii]ion tin- 
direction followed l>y JiUs in CiUs«!S of disease of the cervical viTte- 
bne, or (leep !>uppunitions in th(! neck. 

[Opjiortuirity should lie taken, hefore the ti»nesare in anyway 
«Ti«turlied, to uotiuu the jmrts involved in the ojieiviiion of tyln^ the 
comiuon earotid artery. The vessel may lie felt and inili>-tinctly seen 
«iiclu>>ed in a sheath of fas<-ia, and the jmint where Ihe ligature would 
osnallr 1>ea]>|died is at the an^^le formed hy the sleiiio-ma^toid and 
umo-hyoid muscles, the latter of which can now li.- ~.en thinii.^>h the 
iueia. The anterior trianj^Ie is then ii< l>e ili-sected, after the 
enuiilenition of its contents in the foUowin;; four ]>ara;;raiih> has lieen 
carefully read.] 

The Anterior Triangle (Fi^. l!>i') of ilie neck is a space 
loundeil i/t fnmt by the inetliau line from the '-ym|ihy>is nienti to 
the stemuiu ; Miiit'l by the sterno-ma-<tiiid nni-' Ic : its hinsr is 
formed by the lower jaw and a line from the an;:le of tin; jaw to 
themaatoid piuce*^ ; and its iij>-j- is lielow, at the toii of the sternum. 



438 



THE SIDK OK THE NECK. 



It Jg covered in by the skin aim --uiiiiriciiil I'lwoia, the pljit 
the siiijcrliciiil hijer ot the dceji I'liscia, and the superticial v< 
and nerves, und is sulxlivided into three smaller triangles 
iiiilerior helly of the omu-hy(ii<l, tlie stylii-hyoid and p<j«teriu 
of thi' dixn'^trii.iis, «n<l the IhhIv of the hyoid lione. 

Tlie Submaxillary Triangle is liouiideil iibove by Jhi- Ini 
liorder of the inferior maxillu and the 8tyh)-nmxillury li. 
front hy the midline from thin to hyoid bone, and Imi 
hyoid bone ami the stylo-hyoid and jHjiJterior lielly of the €11',^ 
tricua. Its floor is formed by the anterior lielly of the digiutricu 
the mylo-hyoiil, the hyo-glossu:s, and the middle eoiiiitrictor ; MMi j 
nmlnitit parts of the facial and linj^tial vesseln, with their Mubini'na 
and submaxillary branches, the submaxillary salivary uiiil lympbad 
glandi*, the hypoglossal ntrvt, and the inylo-hyoid brnncbus of tt 
inferior dental vessels and nerve. 

The Superior Carotid Triangle, a small but vriy iiu|M>rt 
space, is Inmnili'd b\ the stylo-hyoid ami jmsterior beljv uf ihf digit 
tricvis iilMwt, the anterior belly of the omo-hyoid Ijelun; and lb 
sterno-mi\sloi(l hrhiiid. Its floor is formed by the hyoid bone, ' 
ihjToid cartilage, the tliyro-hyoid membrane :ind ligainnnt, th 
Bpiue, with the prevertebral iiilisele.s, the hyo-glossiis, the niiiiilf 
and inferior constrictors and a small jiuition of the thyro-byo 
muscle. It cuiUiiint ]iart« fif the common, interna), and exlri 
carotid lu-teriiw, with the superior thyroid, lingual, facial, HM-endii 
pharyirgeal, occijiital, and posttrior auricular branches of the loslj 
tlie superior thyroid, lingual, facial, communicating facial, 
pharyngeal veins ; lymphatic gland.s and vcstteU ; the vogos nrrrfl 
with its pharyngi-al, lurytigeal and superior canliac l»iuinbc»i 
branches of the superior et-rvical ganglion ; and the hyjKigln 
ntTVi', with it.s thyiii-liyoid and descendens cer\'ici8 branches. 

The common cjuiitid aitery comes into view between the »t« 
mastoid and omo-hyoiil muscles, with the descendens cervieia n* 
superficial to it, and the internal jugular vein to its outer «idi': 
the jmi'umo-gaslrie nerve lieiiig concealed behind and between llir 
vessels, and the sympathetic nerve lying still deejjer l>eneutli their 
sheath. The commencement of the extei-nal and internal camtidi 
is seen at, or near, the upjier l>order of the thyroirl carlilagf, anil 
both vessels ate cmssed sujierficially by the hyjMiglosmd iieire, *j 
small twig of which to the ihyro-hyoid muscle shouM lie preserrtnia 
the sujitrior laryngeal nerve njijieai^ on the inner side of the carutiJ f 
vessels, Jiassing behind the internal and external carotid artenm In] 
enter the lar^-nx through the intervid between the hyoid Iwiic uml 
the tJ)yroi(l cartilage, Wlwecn vVi- wviWVc tend wfevioc eonntrictoi* 




I'AKTS HKXKATM TlIK STKHNO-MAVIDII). i'.V.) 

of the pliarynx. Lower (Idwii, a br.iiu'li of tliis ncnt-, tln' t-rtfr-mil 
liirimgnd, ending in the crico-thymiil, slioulil Ik- sniixlit foi. 

The superior thyroid, lin};niil, nn<l fiu'iiil iirli-rii-» arc piirtly viMililf 
in the anterior portion of the »|>iii.'<' : and thi- occi]iitiil iirtrry i^^ seen 
turning Wckwanls Iichtw thu di};a^<t^i(■, with th« hyjioKlnsMal ni;rvc 
curving round itx stumo-miiKtoid 1>ranch or armuKl tht> .>'tcnio- 
uiaftciid artery). 

The Inferior Oarotid Triangle \* iHumdi'd in fnnit )iy thi- 
median lino fn>ni hyoid 1ion<? to wtvniiini, lulu'ml and iilmn: l>y the 
umo-hyoid, Muml and /»/»>/'• l»y thw xti-nio-niastnid. Its Jimir i» 
formed by the ptenio-hyoiil and st«-nK>-thyroid niiisclfs, tht- thyroid 
liody, the larynx, tntchca, ami irsophaKUs tlic tliyniid v<'^<i>ls, «<>nii- 
«niall nen-e^s and lymphatics. 

[It will Ih; uilvisiddu to examine the li^'anicnts of the inner end 
of the i.-lavicle, iH-fon^ detaching it. Tin* sternal ori;{in of the 
«teni<>-iiiJUtoid inuKt W eut, and any riMnaiiis of tln' ]KTtoralis 
major must lie nanoved, in order that tlic li^umcnLs iH'twecn the 
elaviele, .sternum, and first ril>, and also lielwern the two clavicles, 
mar be cleaned. 

It itf ifupiMiseil that the clavicle has lieen i iit close to the attach- 
ment of tlie «>ternu-niasloid in the dissiH'tion of tlie po>terior trianj{le 
of the uevk, lait if this has not iH-en the case it should now \h: 
divided. The inner end of the lioiie In-in;; then drawn up, the 
cojtto-ckivicuhir liganu-nt is to he divided, and tlie knife ]ius.-ed inti' 
the stemo-clavicuiar arlicul.-ition from lielou, ami clo>e to the 
rliivicle. By this, one of the two synovial nieinliranes will U> 
opened, and the other can In- expoMeil ]>y cuttinu' from almve cIokc 
to the Htenium, thus leavin-; the inter-arli<'ular ciirtila;{e uninjured. 
The iuter-articulur filiro-cartila^e is to be divi<h-<l and the inner eml 
uf the Ixiue dislocated, the lilires of the stenioliyoiil which are 
attached to it heiu}{ wiKimtwl. Theslerm>-inast«ii| (witlitlie portion 
«f the rhivide) is then to be turned back, In-in^ carefully 8eparated 
from the fascia liem-ath. The sjiinal-accessory nerve will be found to 
pieree it at the upper part, and a bninch of the :jnd cervii'al nerve 
eiiterH the under-surface of the muscle. | 

Farta beneath the Btemo-Hastoid Muscle. I !y the reimival 
of the stemo-niaittoid the foUowiii},' slructur<-' will lie lirought into 
view, which must Iw sul>set|uently studied in detail. .Vbove are 
i)een the jxisteriur Ixdly of the digastric and the st>lo-hyoid; with 
the posterior auricular artery and parotid };lami at the u|i|H-r iKinh-r 
of the digastric, and the oeci])ital artery at the lower border of the 
same muscle. Lower down and iKisteriorly are ]>arts of the s]denius 
eapitis, levator anguli soapuhc, ami sculenu.i medins, with the cervical 
nerves and lymphatic glands. In front, iniinvdiatelx below the 




utrvi- ami u. biuntli of tliir untfriiif 
rTvv will \m r»unil jiii-rciiij; tlu- ilctii 
niuutoiJ, uml tliii hyp(iKlf>>iK;il iktvo arching 
N»tiil vrjiiicl». Th.' ooiitTiiiin rnhiliil, with ili" 
• vt\n i-xWrna] u> it, and tlu' iPiiniiiini-;,'!^!!-!^- iicn'e 
IwiM-ii tliK two, Hi>|M'ar» in ii Hhi'uth of fuw.iii alH)v«! lbs 
omo-Ljoiil ; anil tli« ilescctidemi ciTVloiit nerv« lie» 
'in lli«? iheath, nnd fonus unr or more loop* with the 
in;,' linuicheit Cruia the cervical plfxu«. Tim hifuivntinu 
j^irill be M-cn about the- li-vt-l of the upper lnpnliT of 
Hrtiki!e, the intnnml cjirotiil ])ivwin|{ iipwanU by tho 
Qfuliir vein, with tin' i:xt<Tnal i'(in>ti<l in front of It ; the 
nr.hc* of till'. Initi'r ri'iuhinj! f-irwnril beyond ihi- "l«;nio- 
I tile lUixTior and niidille thyroid vein* oponinjj into the 
lllar. Near ihi- cluvich- are thr omo-hyoiil, (stcnicv-hyoid, 
hyniid miiwlu^, tlir tnimivrr4<ili« rolli and lraM>-v»'i>«li» 
^Uie untiM-ior jiijiular vein iirar itJ< ti'rmiiuition, and, 
frior bcalfniiH with the phrt'iiic iiiTve upon it. On 
Jhi- bi^ly, tbi' thoracic duel will be found arching; 
Dnt (if thi; aulx'laviun artery loojwn into tin- junction 
jdgtilar and nubchtvinn veiiw. A siinilnr but unuiUor 
iic truni) may Iw found on the rijjht Hide. 
Boendens Cerviois Nerve (Fig. 2<M, 14) in now 
tout. It lied oithcT upon or within thi" sheath of the 
land is trt be trace<l u]>watd» U> tin: hypog|o«K;d niTVe 
hv rnMtid Kheulh jntit Iwlow the diximlnc niuncle), 
to supply the niU'tdeii iu the front of the neck, 
J, itfenio-thyruid, and omo-hyoid. A branch, which 
ble, will be found to come forwanl from the ci-nicnl 
in the hyjiogl(j»ml and form a loop, the muit kijiuitiliifi, 

Pt<--nio-maHtoid. Thia is the fniiiiniininin* rrtfiru 
comes from the and and 3ril cervical nerves. 
m to the Thyro-hyoid in seen i-oniiu(; from the hypo- 
llBt of the orij^'in of the dettceiideiis cervicis. Thesti 
Btogrtber with the nerve t<> the gcnio-hyoid, ore 

nticut •ud rectui cupitij 




jufnUr vein (beneath 

fpUUB, 




Tlu' Sterno-hyoid tB'if,'. 2(>:?, 14) is tlie luont «u)>erlicml luincV. 
it in siliiinUt.-il lii/iii il". I'lllciw nf llir njijMwili' -liili' liv ..niv i <iimll 1 



FiK. 20:). — Mii«cK<» of ihe niiU'rior asprit of 
liRiiiT the miptTluiiil niiixrlc* are Been, on 

1. Posterior lii'lly of (liginlric. 14, 

2, lU aiil<'rii>i' liflly. Anoiiuunitir \o. 

Jmllo), tlirougli whica ils t«ii- 16. 
Ion is sf-i'n piisMn^, attnchcd lo 17. 
Ilip lioilv of I 111' UK liyuidea, IS. 18, 

4. 8tylo-hy«i(l inuisclo. 

5. Mylo-hyoict niuH'li'. 
a, Clotiin.liyoid niuM<'Ie. 
7. .Slvli'-xl"«>u»- 

K. llyo-Kloii^UK 1!), 

ft. Slyloiil prorefi>i. 

10. Stvlo-plinryncpiis. 20, 

1 1 . Stj,'nio-t-Ii-i()o-llm&to;<I(-UH. 
1:!. Its «t<Thiil origin. 21. 
J.'i. ?(* cliiviiuliir oriaio. 



the Dei k ; on the lift (liili' of fit 
tliL- riglit tin- deep (fpim Wil»»). 

Stemo-hyind. 

Stcruo-tliyroid of tliw ri{ht titW 

Thyro-liyoid. 

Anterior IhIIv of tlir niDo-lnniil. 

18. Its posterior bfUy : on in- ''' 

>'i<lc, the tendon of tln' ■■:■ 

isacvntn lie lM:iund (lov.i; . 

portion of the deep itin'si 

fuM'iu. 
CliiTiruliir pvrtiou of the tn|»- 

zius. 
SiNiJEmus untieiu, of (bv riftkl 

aide. 
Scalenus poatinu; thr M-ala 



THK IIIOAXTKIO MUsrl,K. 



■^43 



inlervul uliuvc, but divcrjfce rmm it In-low. It urun from 
ck of ihf iimt pii-i-i^ of tin- •■U-riiiiiii, the jiostrriiT ulenio- 
Mirnt, itnil tlir inner cxth-iiiitA of thi- claricln : and ii> 
.• IkkIv iif till- liyoiil liiiiU'. 

' iif (lie liyuiil In>iu', iixhm it iluriiix t1i»^ ni'^tion 
i luiurlfit. It tiiHy ucl feel)l\ iw u liiil>u'|(> of 
ktiuii, Ity tauitix tbf olrriumi wlieii tliu byoid lionv i)> titeA 
ve. 
lit- Stemo-thyrold iKig. io:i, i;;) i.^ iIvc-imt ntirt lir<>»ili-i' tbmi 
piTCpdiiij; niii»cle, by wliich it i» iwrtly covmil. It arut* 
I tbr ImcIc nf tb* Nivrnuin 1k-1o»' tb«- itlfrini-byoid, nn<l frnm tbr 
w lUietiilM^ lbi< vKittul wwlal i-urtibi)(t' ; uiiil i» iiuurttri 
obliiiiii' linv on tlte kiilu uf tlit- ibrmitl c:iriiLH;i'. It vi-ry 
ally b&9 a tninnvt-ifiv t«riidiiuiii» ititftx-itiun in itx libn-s. It 
• tepanit«<i from it^ fi-llnw uIhivi- by n I'unHidi'riiiib- intt-niil, but 
into I'bKL- contiijiiily witli it InOdW. 
i« • <lciiiv»iiii nf till- ibyroid cjiiiil:ix»', "lid » fi'flib- fJRvatiir of 
ti-miim ivbi'li till' riiHrlH;.;!- Ih druwii ttpwiiTiL< iiud tui'd. 
ThjTO-hyoid il'iK- -"•', i6) i" a dirw-t ciiiitiiiUHtion of tbi' 
It iiriMt from tbi- nbliijiic* lim- nf tbr tbyruid l-urtibl^e, 
bKncatb tbf uirir>-by(ii<l in iitm-rl"! into tbi- luwer In^nliT 
le LkmIv and grrntrr lomn of tbc bynid l>ono. 
; i« an rJrt-ntor of ibf tbvroiil •nrtibi-'i' m-tinj; fn>iu nbovr, and a 
I>n9«cir nf the bynid bono Acting' {toni ludow. whni the tbymid 
is drown i|i>wnwunU and 11 mm!. 
Omo-byoid i Fit;. -i'3> ' 7 ' "^"i ""* I* •••'<-••» in it« whol«< 
cr<mxin}{ Ui>- iii-ck bt'Ui-utb llir Hti-riiK-uuinloid, und cOli»i*t- 
' twij ln-Uies united l«y a .-iiiall tciidoii, wbii-b bii» Iwi-Ii »eeu 
held ikiwn U> tlu' cbividc iiiid lit>l rili by a jirmirsH of tlie 
f f'-nienl fowia. It i>riir» fr<ini tin- n]i|M'r nmi->{in of the seiipubi 
tidi, «ri<i fciiin ibi' traii»viTxi' lixinii>''it wbirb lonvcrtit 
iiliir iiotrli itil<i a foriuuen ; und i» nnurlnl into tbv boiiy 
byoHl Ihiu<< i-xtemully to the vtirnu-byuid, and auiMirllciaUy 
tJiyro-byiiid muKcle. 
I • dL-prfsaor of tlu- byoiil bom- mid ii feebb- eb-vator ol tbf 




tlirco niuades are all miii/ilitii by thn ilesccndeiis carvicia 
cxcvjit tbi^ |idHtfrior liclly of Ibp oni<vbyoid, wbicb n-rfiw* a 
|> from till- •iit'ii liiiymiliu'n. 

Digastric iKij;. i03, i^ tnumb- i-on«i»t» of two iK'Uiee, 

nJ«ii>- lb<- byoid bone, to wbicb ibi- iutfmiediult- tendon i« 

It nntn from tlie di^n'-tne foxsa on tbc initer 

) jiroiv.** Ill tbe tedijioiid Uini- ; iini\ \* i««rrtMl 



Ui 



THE SIDE OF THE NKCK. 



into a rough siirl'ui'c at the lower horiliM' ol' the hifuri<ir 
close to the nicdiaii line. Its net inn is to depreaj tiic iowur j«w, fir| 
the jiiw is fixed, to rftise the hyoid hone nml liirj'iix. It» p« 
belly is giii>f)lie(t liy a branch of the facial nerve, and the anltria 
by the mylo-hyoid binnch.of the inferior dental nerve (Sth). Th 
subniaxillury siilivary gl«nJ lies in the anjjle between the two 
bid lies. 

The Stylo-hyoid (Fig. S03, 4) i» the niuwle in itnaiediate ceo- 
nectiun with the [losterior belly of thf digastric, und is 
by the tendon of the latter chwe to the liyoid l>one. It oris 
the outer or jioaterior jxirt of the biuje of the ^tvloid prtHcaaj 
teni]ioral bone, and is imirtal into the upper surface of th 
of the hyoid bone at it« junction with the {,'rent comu. It i* 
elevator of the hj'oid bone and Ls mtpplied by the digattric lirun 
of the facia] iien'e. 

[In order to show the sheath of the airotid vessels conipleta 
stirno-hyoid and slemo-lhyroid must I* reflected. But lietur«l 
ISO the dif<.<ieetor of the left aide should seek the tei'tinnation of 1 
thoracic duct {r. p. 4o8). 

Alter the muscles have been reflected the sheath is to \k opcn<.-4 
The desceudetm cervicis. JUTve hiw already lieen traced uim>u it, i 
within will now be found the common carotid artery neju 
nieilian liiui ; more e.\ternally the internal jugular vein, and 1m 
b.it lieliind these the jineunm-yrtstric (or va^jus) nervi'. Behiri 
shcnlh will be found tlie tnmk of the sNmpathelic neive, l»i 
parallel with the vei^hcls ; and crossing beliiml these at the levil i 
the (ith cervical verlelira will be seen the inferior thyroid artery 
recurrent lurynj^eul nerve. The sheath is to be carefully iliwecte 
away, and the bntriches of the artery and the vein lollowed o»t i 
cleaned, a-s far as the dissection will penuit. The large bypojjliu 
nerve will be found lcHi]iiiig round the occipital or i^tenio-nia-slo 
artery, and crossing in Iront of the external imd iuternul CiUOtJd 
in a curved direction ininiediiitely belr)W the di^a.stric muscle ; an 
the sujicrior laiynceal branch of the jmeumo-gastric crosses bchin 
the vcsselb a little lower down.] 

The Common Carotid Artery (Fig. 2(»4, 14) has the sam* ' 
ixdations on l.otli hides of the neck from the sterno-cUjvicular atfjcii- ' 
latiou upwards, lliough its origin is ilitl'ereut on the two aide*. On 
the right side it comniences behind the toj) of the sterntxlaricuJiir i 
articulation, by the bifurcation of the innominate into commoq 
carotid and subclavian uiteries, but on the left .side it lieguis nit 
the arch ol' the oortii. Its direction in the neck is upwonU iml tj 
little outwards, and would be sufficiently indicated by a lin^ 
the inner end of the clavicle to tl\e (vmvt o( the mttstoid 



THK COMMON CAKOTII) ARTKRY. 



445 



onliiuuily iliviilr* at llie levid of the upptT Imrilur of the tlijToi«l 
ilAgt< intii «jit«Ttud mill iutcnuil i-arntiiln. 
It" rflaiioat are — tn /ronl inpcrficial utriu'liintJi iiicluiliii)( th« 

V\t. 204. 




Fig. Wt.— Ill* fUe of tlio urck (drawn by J. T. Um}-). 





U. 


Cimi':-' -,-■<■■' -■•> rv with (It.. 
*■ I Vc. 


\ niirvc. 


lo. 


IlllM .uUf.l«l). 




1(1. 


MlTl|i.-ll>.li). 


1 U'lll. 


17. 


Subcl.niull Vcill (out). 


t VB. 


IH. 


<)ll|r>*ll)l>ul. 


rricM nerve 


19. 


Siilx'inviiiD nrtrrjr liviitK ulT thn 
thyfjUl axU ami the iiilvrtiiil 


ni'Mc. 




inMttiiiiiin- nrtt'ry. 


Ill lUTTf. 


20, 


Miiidl.' i^rvicttl Kunglioii ol »ym. 
{mtliftir. 


' V» 


21. 


A|M*x t>( (lU'uni, 



iretle-tvd). 



,_<. 



44(5 



THE SIDK OF THE NKC'K. 






1 



(.l.tn.^um, the slenuil origin and anterior lidnler of thw 
luiistoiii, the lower portion of the sterno-hyoid mid «temlHthy^ 
miiRclt"*, the stcniivmnstiiiJ limnoL of the mi[i«»rior thyroid uteij 
til"' inleninl juj;ulnr vi-iii iit the root of the nts'k on the Irft 
Mil' iiiiihUe iiml superior thyroid veing, the antvrior jiiguli 

si']mnited from the artery liy the stonio-hyoid unci »teriii> 
niiiBtles), the hypoijhtssal nerve, iitid a jiortion of the Literal ] 
the thyroid l>ody. liehiud aix- tlie three lower >ervical an 
ii]>l>er doisul verU-hra;, witli the lunj;iis colli and n-etus capitis onti'' 
major, llie sulirlaviun artery, the vertebral and inferior th_»T 
arteries, the recurrent laryngeal nerve, the sympathetic i-md 
laidille cervical ^{unglion, the thoracic duct on the left *i<le and i 
ri^ht lymphatic trtink on the right. Extn-imlly are the iutrr 

ugular vein, which overlaps it l)elow on the left f.ide, the pneuu 
trie nerve, ami tlie a]>ex nf the lung (esjiecially on the left »i/lcy 
Huil intrrnnllti the trachea, h>r\"nx, thyroid hody, phon'os, 
pliiigux, and recurrent larvnyeal nerve. 

The point of I Mimoii carotid may v" 

liut i.s more frei|i hIii w the upper bm 

ijiyroid cart-ilty^e. Tlie ve*-iel is liomewiiiit enlar^eil at its terutuu 
tion, and here is cKwelj' related in front to a vascular glomeTulg 
(which resembles a jnaiM of connective tisnne in the deail snbje 
railed the fitriitid mmjliini. 

Stirgery. — To lie Ikr rumiumi earolid arUnj. This may l« acn 
plisheil either above or below the onio-hyoid, but above thf miUk't 
H the belter situation. An iniision, thive inche* in length, alon| 
till- anterior border of the steruo-nuiMtoiil, beginning! at the le»-« 
of the liyoid bone, will allow that muscle to iie tiirneil o«t» 
sulliciently to brin<,' the onio-hyoid into view. In the angle l>ctW(« 
the two muscles the carotid is to lje found, ami this part of tin 
operalitin will be much facililat^-dby drawing the oiuo-hyoid tomu<ll 
the median line. 

Tlie descendcns cervicis nerve may be seen on the sheatli of the j 
vessels, and is to be avoiiled, and the sheath is to be csrefnJly 
opened on its inner side, so as to avoid ])os.<*ible injury to the internal ' 
iiignlar vein, which usually it* not exposed. Tlie needle u In W 
passed from the outer side, cjn-e being taken not to include the 
pueumo-gastric nr the sympathetic nei-ve. l)n the diuid bmly \ht 
vein is frei[uently eiiiiity, and is liable to lie injured nnleM tLf 
sheAth 1* openeil well to its inner side. 

The operation below the omo-hyoid might he jjerformcd thrutlgLa 
similiU' iiii-ision along the border of the lower part of the tteraiv 
mastoid, but woiiM be facilitateil by dividing the sternal origin uf 
the muscle. The slerno-hyoid ami steriiu-thyrnid mu.scle'* niunf )*• 
turned iuwiuiis, iir even divided, in owVct to teach the vessel 




THK INTKKXAI, CAKnTII) AUTKUV. 



147 



The Intamal Carotid Artery > Ki^. ;{<).'>, X) iitcciuU tu tin- Uim; 
of the skull, lying cIoik* tu the pliuryiix, utul -uiion tli« |>n-v<-ii«-l>nil 
miMfil^ t*"* **fi"*i .ttn*l the syiiiimtlictic run). It ix iirst to tin- 

Fi)c. "JO-i. 




Fip. 205.— The camtiil nrtrrics (W. A.). 

1. Tdnponl. <.). Fni'iiil. 

t. tmHirm auricnlar. 10. KiiliirKi'iiK'iit >•( carotiil :it bifur- 

S. Intenial nuxilluy. ration. 

4. OadpitU. II. Unciml. 

C Bvoad and Buaetrrii'. I'J. ('oiinnon ciimtiil. 

4. Manw-maatoM. 13. .Superior tin miil. 

7. MMMuUag phaijriiRral. 14. Strmo-niiiKtoiil hrniU'li of aupcrinr 

t. lataMl eaivtid. thyroid. 



SIDE 



outer side of the extenml carotid, and is cronsed in Jrmit 

hypojilossnl iicn-e, the di>,'aitric ami gtylo-liyoiil ninscles, .-.■ 
jiosteiiiii' auricular and (iccijiital urtwit-i' ; ami lyhinrl hv tli.- 
li<ryii|ji'al liiiinch of tlie )iii<;vinici-j;a8tric-. In lis furtli- 
dwiifr than the vxteniul carotid, uti<l L» sepaniltd fi-' 
styloid Jiroi'i'ss, the stylo-glosaus and stylo-pharvnj^eiis irju.->c;. 
glosso-plinrynReal ner\e, and the pharyngeal bnuicli of tin- i i^v 
Finally it enters the canitid canal in the peti-oii^ bone. 

The artery will bo more fully traced out in the tleep liiMMtioii 
of the neck and pharynx. 

The Bxtornal Carotid Artery (F)gi>. 2<>-», 205) ii. ilerr„| 
from the couuuon wrotid iipp<>6ite-tlie ujijier^ boi'de£_of_U»c -liu 
cartilage, and, lying at first to the inner side oTand t}i( n 
U) the internal carotid, a-icends in the substance of the i 
to a jioint oj)])oi>ite the neck of the condyle of the lower j.iu, wkjn 
it gives oir its terminal bmiicbes. Supf.rftfinlhj in tlif; neck It i- 
crossed by the digastric and stylo-hyoid nmscles, the hyi»i;! i'. 
nerve, and tlie lingual luid facial veins, and dd'i'lij is iseparatctl iiin 
tlie internal carotid by the styloid proce**, the stylo-gliBsm m\ 
*lylo-pharynge«j muscles, the pharj'iigeal branch of tlie viigus, *iiil 
the gloBso-pharpigeal nerve. It enters the parotiil gland heliiml 
the angle of the jaw, and in the glatid lies IjeneatU the ti<ni|>ui 
iiiaxillary vein and is crossed superlicijJly by the facial ncr^e. 

Its hranches may be divided as follows : — 

Anteiior set ; 1, Superior Thyroid; 2, Lingtial ; 3, Facial i 
I'arijtiil and Masseteric. 
►V I'oslerior set: 1, Oecipitul ; 2, Posterior Auricular; 3, Sicmo- 
■J^Iajiloid.* 

Ascending branch : Ascending Pliaryngeai. 

Terminal branches: 1, Temporal ; i, Inteninl Maxillar)-. 

The anterior and jjostcrior st'td can now Ix; partly di'awicU'd ; 
rest will be given in other di.ssections. 

The Superior Thyroid Artery (Fig. 204, la) arises dose to 
the bifurcation of the common carotid, and sometimes from lh(< 
main artery itself. It runs forwarvl beneath the depressor nn- '^ 
uf the hyoid bone, and tlien downward to the thyroid body i 
tomoBo with the inferior thyroid artery from the suljclavian nii'. 
the thyroid ve.ssels of the opposite side. It gives off on • 
hyoid hranrli, which runs along the lower border of the hyoid Imu^ 
and anastomoses with the hyoid branch of the lingual artery ; ■ 



BO- 



■ Tbnftemo-iniutoitI i» ]>crh«p8 mure frequently derivni from tho occifi 
thou frou Ike trunk itwif. 



THK OCCIPITAL AKTERY. 



4">9 



MV 



larynytal hraiich, which pii-rcco the- t)iyri>-liyoiJ lucmbraiiv 

with the comajionding nerve ; a criro-thifniid brunch, utuutomcMiug 

vitb iu fellow of tbe oppcoiu- ilde ucnma the rriuo-Uiyroiil tiiciu- 

binne ; Mul a mjierjirial dttcfiidirtg brunch, which Ktniplios thn 

dtrpwwM-r niiMclcM of iho hyoiil l)<)ne, iinJ gives off u utrtnn- 

irL'id hraiich is winsiihTeil to \<v one of the cause* of 

ngotomy, but if the iiieiubraiio \» pieix-ed tniimvet»ely, 

rily i* m the ojierutlou, it<i JiviAinti ia tmliliely ; motv- 

ill size wouhl cnuxe <uch ai\ lut'iileiit to l>c of but little 

OltMice. 

he Lingtial Artery {Vif,. 204, 8). — Only n very umiill jHirtioti 

hntfiiui artery i» now vititilc, nmning first upwnnln ami then 

vcr>rly upon the uiiihlle cuiiHtrictoruf the phiirynx, immediately 

1 the gninter conut of the hyuid bone, to diiuip{>eur beneath the 

jh the tibnas of the hyo-jjlossus muiic'le. It in crcia»etl 

lo (lUil ctylrt-hyoid muwlea and the hypoghwiuil ucr\'e, 

1 i.v the •nbnmxillitry glund. The rt^nininder of the 

1. M lilH'd ill the dissei-tioii fit the kiibniikxillikry rention. 

he Facial Artery (Fig. 2u4, 4) juixncjt iipwniik mid forward* 

pcjitli UiL- digiiilric aud ntylo-hyoid iiiiiorU'x and liypoj^lowul nerve, 

Ifomu a remarltnble iiigiuoid eurve ox it lii'» in a deep groove on 

{HMterior {Nirt of the ■•ubuuixillary gland before reaching the 

)»». It CTo«BC« the juw with the facial vein lo \U outer side, 

imuii'dtiitely in finnt of the iniuseter muscle, and will bo followed 

nut in Ihe diiwition of the face. It* iii/eriirr fHilatiiui branch inuy 

' '. li-mpiitsariiig between the stylo-gloMUn and ntylo-pharyngeiut 

and the taimlUir biiuich lietween the »tylo-glo»»UM and 

: k-us intemil!) ; itit tnbtiuurilUtrij branclieii (two or three) 

• ginnd, and tlie tuh-vtrutal hrinich, often of large sine, runs 

-iiyoid muscle to the chin, where it supplies 

-< nml anaKt4>tno.'«eA with the sublingual, 

!rVoid artericd. 

I y arises in common with the Ungual. 
lie Oocipital Artery (Fig. 204, r) in only wien in il« lin»t port. 
Inm biu-kworxia along the inferior Iwrtler of the diguatrie, and 
tiim iM'nrath il« origin in a special groove in the miutoid jiortion of 

"■ ' I >ione, and may usually be recogniacd by the fai-t th.it 

d nen'c hookj round it* sterno-mastoid brunch when 

I'-i lit. Tlie artery cro«»ca the hypoglovuil nerve, internal 

pneumiHgiixiric nerve, inti'rnal jugular vein, ipiiud 

nen-c, and Hyniputhetii' trunk. It usually gtveo off a 

itoid branch. Ita further course will be traced later. 





450 



THE SIDE OF THE NECK. 



The Posterior Auricular Artery, <)f much eniAller I 
thfi last and not easily seen unless carefully looked for, aalt» 
beueiith the dijjistricuw uiiil tuTnis around ita iipjier bonier to mk& 
the mastoid pi-oc«s8, which it crosses. Near the iwantoid ]»roc«» it 
gives oif the slylo-moiloiil branch into the stylo-nuuitoiil f'^insMO, 
and then supiilieK auTxctdar, mattoid, and temporal biancbtw tu tiur 
pinna and the structures of the niiistuid and posterior !• t: ' 
region, besides sending a small branch benealli the poatcri- 
of the oecipito-frontalis. It anustoniiii,e6 with the temporal i^M 
occipital arteries. ^M 

The Bterno-Mastoid Artery is a branch of uniertain (>rif(^| 
coming either from the ej^leniul carotid artery near its romtueo^l 
meut, or from the occipital artery ; the hyjxjglossal nerve wind^H 
round it in either ciuie. It is of Aniull Bi:cc and enters the nn^H 
surface of the stenio-maHtoid muscle, crossing the cArotid »he^^| 
to anastomose with the stenio-iua«toid branch »f tlie oupei^B 
tliyroi<l. ^U 

The Veins corresponding to the branches of the external cam^H 
artery do not take nuile the same course us those vessirl?. H^l 
internal maxillary and temporal veins unite in the ])arolid to frji^f 
the tempoTo-maxillartj irin, which aftenvanls receives the pttMer^^M 
auricular rein, and pitsses down in the substance of the gl.ind t^M 
the outer side of the external carotid arteiy ami facial nerve ; ^H 
the angle of the jaw it diviiles into the fjtmiitl juyular juui tl^| 
facifil fowvtwiiriititig. The latter joins the facial vein to form ti|^| 
cowmmi faa'til, which enU-i-s the Intenial Jugular. The faniil ft^^t 
ia more superticial than the artery and runs over the sulimaxilUa^i 
gland. The tinyiial vein usually joins the facial. The oceiirital w^^ 
seldom accomjmnies the artery, but generally ends in a nctwa^^d 
beneath the complexus. ^H 

The Internal Jugular Vein (Fig. 204, 5) is deeply placeil ^B 
the outer side of the internal <-arotid artery immediately beluw H>. 
base of the skull, and afterwanls hold.s the same relation to tlr 
common carotid artery. It jh crossed by the styloid pnxcsa ukj 
stylo-pharyngeus muscle, the spinal-accessory nerve (which, ho^^H 
ever, is sometimes beneath the vein), tlie digastric and stylo-byoj^l 
muBcle« and the occ.iiiilal artery. It is covei-ed by tlic ston^H 
mastoid in the lower part of its course. It has the piieumo-gaitri^l 
n<-n-e between it and the internal and common carotid arterir^H 
and is enclosed in the carotid sheath of cervical fascia. It recein^^l 
the facial, lingual, jtlinrijiiijral, supcrinr thyroid, and mitldlt tAyrni^H 
veins, and unites with the subclavinu vein to fonn the rtna um«^B 
miiuiia. Its relation to the carotid artery differs on the two <idc»^| 




THK SflKJI.AVIAN AKTKIUKS. 



4.-)l 



At the root of the neck, on tlic left huIv, it soiiiuwkat ovcrltips the 
*iteiy, bnt on the right is Heporated fiiiui it by u r'liiull luigiilur 
intervaL 

[The inner end of the clavich' having heeu ritniovuil with the Htcruo- 
uutoitl, a little diweotion cIuhu uIiovc tlx; Mtin-imm will reiulily cximmo 
the tcalenuH anticus luiwlc attacht^l to the tiixt rili, huvin:^ thu 
lirenic nervi- lying upon it, aud biuiidiuH of the thyniid hxIh ct-osa- 

>g it. The pneumo-gaotric if tniot-d down will W found to i-romthc 
fint put of the subclavian artvry, which with itH bmnchu!) i> to bi- 
defined. The aynipathetic, and the thoniuic duct uii the li-ft .'•i<lc,ni'u 
to be euefully preserve)!.] 

The SubolaTian Arteries ditfur on tlu; two sidi-H, thu right 
heg^iog at the bifurcation of the innominate oi>]MKiit«- the Htcnio- 
clavicnlar articulation ; and the left in the thorax at the un:h of the 
aoiti. Both arteries nuty be dividnl into thri-c jiurts, of which the 
eeeondand third correniwnd on thf two xiilfn of tlic Unly, while the 
cenicil portion of the finst jmrt of the left dlHci-s but little in itH 
nIatiMH fruiu the lint jNirt on tli«- right ^id<>. 

Ibt fint part un thf ritjhl siili" i-xUmuIh from tin* bifurcation of the 
innaminate artei}*, iH-hind tin- u|i|M-r border of tin; stcrno-clavicular 
aiticnlation, to the innt-r nuirgin of the Hcak-nuH unticux. itn 
eonweis obli<iuely upwanlft and outwaiils. It is related in Jfont to 
tlie itemo-mastoid, Ktenio-hyoid, and sterno-thyi-oiil inUM-leH ; tin- 
emnnKncement of the coniiuon eai-otid artery, the internal jugular 
•wi vertebral veins ; the i>neunio-giu«trii:, ivirdiac, ]ilirt:nii', anil 
'Cetuient laiyngeal nerve ; and the right lyni]ihatie. triuik. The 
mbcltvian vein, if greatly ilixtendeil, nniy overlaji it.i lower boiiU-r, 
''^t the innounnate vein in Ih-1ow the level of this |iart of the 
•teiy; the anterior jugular vein crosses it tnuisvei-sely, but is 
'^pinted from it by the Ktenio-hyoid and uterno-thyroid muscles. 
^efcwrf it lie the njwx of the piKiini, the njcumnit liiryngeal nerve 
\^]iieh also parses around it Ih-1ow), the syinpathetie. cord, and 
•oine eanliac nerveti. 

TheySnt part on the Itft Kiilr extends from the arch of the aorta ti> 

the inner border of the sodenus antitiuo, ami may be eiin\'«:niently 

*<lbdiTided into a thoracic and u cervical {N)rtion. Tlie relations of 

4m cervical part ore the Hiune us those on the right nide, with these 

Exceptions : — The recurrent laryngeal nerve does not wind aiiiund 

It ; the thoracic dnct arches above and in front of the artery 

V> ynn the subclavian vein clu'<e to its union with thu internal 

Jugular; and the internal jugular vein, overlai>]iing the common 

^sarotid attcxy, is less extensively ^.'1atL^l to the sulx-laviau artery 

than on the qght side. 



452 



THE SIDE OF THE NECK. 




The Branches of the first part of the gnbclavian aiteqtl 
Vertebral, (2) IntenialManiniarj-, find (3) Thyroid Arw. TheSiiprriur 
Intercostal iirteiy arir>cg from the first part of the fiiil)claviati on lit 
left side, but ou the right is usniiUy a branch of the i>econd put, oki 
is concealed by the inner bonier of die gcalcnun anticos. 

Fig. 206 




1. The Vertebral Artery (Fig. 200, i) ia seen now in i 
xniall jiart of its eouive. It arises from the posterior part of the 
upper border of the 8ulicla\'ian (occasionally from the aortA on It* 
left firle), and runs upwards in front of the transverse prucoi t 
the 7th cervical vertebra, lying in an interspace between the s ~ 



Ki?. 206. — Tlic riubt subclarian and it» branches. The doited ontlinn 
tht poKition of llie .•.ti'muo), 6nl rib, clavicle, and sculcnui onticiu (' 

1. Vertebral extending upwards to 6. Thyroid nxis. 

foramen in 6th ceniosl rer- 7. Superior intercnutal. 

tcbni. 8. Innomiuate (Ihr •)""■■■' I'" 

2. Inferior thyroid. iponda to the m 

3. Deep cervical. 9. Posterior scupulu , 

4. Common carotid . 11. Supra-wnpular. 

6. Truusvci-BC cervical. 13. Intemnl inanuiuiry. 




THE THYROID AXIS. 453 

nticuB and the longus colli luuaclcs. In front of it arc the inferior 
kyioid artery, the iniildle curviual tpuagliou, two minute branches 
Etom the inferior cervical ganglion of tlie Kynipathulio, imd the internal 
ingalar and vertebral veins. It enters the fomnien in the transverse 
poeeas of the 6th cervical vertcbru, nnd inimdcs through the vertebrar- 
teiial foramina in all the vt-rtflinii ultovc, inclining outwards to 
jeieh its passage on the utliis, then winding iuwanU u]K>n the 
atla* to enter the foroinen ningniun and Kuitply the brain. It is 
about i inches in length between its origin and the ]>i)int at which 
it enters the vertebrarterial canal. In the neck it gives otf ititiiud 
branches, which enter the spinal cunul through the intervertebral 
foiamina and are distribute<l to the walls of the canal, the nerve 
loots, the spinal c/>nl, and the meninges; and viiiiu'ulttr branches 
supplying the retro-spinal muscles, and anastomosing with the 
piincejjs and profunda cervicis arteries beneath the cum)ilexus. 

The Veridnnl vein, much smaller than the artery, commences in 
null branches about tlie foramen magnum and atlas. It takes the 
nme conne as the artery, receiving rorresponiling branches, and 
abo the (ueendiug optical and drep crrviral vein.'*, and, after emerg- 
ing irom the foramen in the sixth vertebra, is joined by a snmll 
tribotaiy which runs through the fommen in the xeventh vertebra, 
ad cranes the subclavian artery to open into the innominate vein. 
It aometinies e8ca|M.-s through the foramen in the tninxversc process 
4f one of the other cervical vertebne. 

1 The Intenutl Mammary Artery (Fig. HHi, 13) arises from 

the lower part of the anterior surface of the subclavian artery on the 

diiUd side of the vertebral IhjIow the origin of the thyroid axis, and 

It oooe descends into the thorax. It is crossed suiierlicially by the 

phR&ic nerve close to its origin. The artery passes l)t.;hind the 

cmUI cartilages of the true rilis, giving off a <!onu's nervi phrenici, 

aterior intercostal, mediastinal, pericanliuc, and iierforating 

h me hea , and finally divides opismite the seventh cartilage into two 

termioal branches — sui>erior epigastric and musculo-phivnic. These 

will be further seen in the disse<;tion of the thorax. Tlie artery is 

■eeompanied by rente cnmitei, which unite above and join the 

innominate vein. 

S. The Thyroid Asia (Fig. iOG, 6) is a short thick trunk 
irinng from the npjM>r part of the anterior surface of the sub- 
Javiao, close to the inner border of the scalenus anticus and 
atonal to the origin of the vertebral. It divides immediately into 
line bianchea, (a) inferior thyroid, (6) transversalis colli, and (c) 
wpwricapnlar or transversal is humeri. 
0. The Infmm Tkyroid artery (2) runs first upwards and inwards 



454 



THE SIDE OF THK NECK. 
Fig. 307. 




Fig. 207.— Schniie of the principal anai<tanio«cs of the subcUrisn tnd 




THE TRANSVEKSE CKUVICAL AUTKUY. 



4r,.) 



ictoM the vertebral artery ami l>eliin<l ttic riirotid HhiMith and sym- 
[ttthetic trunk. It cnrvcjt iiiwardit and downwanls oppoiiite the 
traiiSTcne process of the 0th cur\'ical vertebra, then dcKcendg iia far 
m the lower I)onler of the thyn>i<l ImmIv, nn<l after jNuwing inwania 
Mind the recurrent laryngeal nerve (an imi>nrlant Rurgical rela- 
tion) it turns upwards, furniin<: a Kecund rurve, and breaks up into 
bmches which supply the tliyroid b(Hly and anaxtomose witli the 
•qwrior thyroid artery (Fij». 211). Ik-Hides irnnphaijinl , trnelu-ai, and a 
smiall wfcrinr lanjiiijml branch, it usually gives off olnse to its origin, 
the luetHilinij cervical, whicli runs upwaiils in front of the anterior 
laberclesof the transverse j>r(x;ei.scs of tlievertebnu between the att4ich- 
mcntdof thescalenusanticus and n-ctuscapitisanticus major, supplying 
the prevertebral muscles and anastomosing witli brandies of tlie verte- 
Inl artery. The middle cervical ganglion usually rests u|ion its tirst 
can-e. The walls of this artery are said to be very thin and larcnible. 
Tlie Inferior Tlnjn>iil r»:iH# \waa down in front of the trachea, 
•fter forming a jdexus Mow the isthmus of the thyroid IxKly. 
Hey open into the innominate veins ; the right often crossing 
obliquely over the innominate artery to eml in tiie left iiuioniinate, 
or, less fre<|uently, in the right innominate. 

h. The Tntiurirte ('ervintl artrry riiiLs tniiinversely outward in 
front of the scalenus anticus and plin-nic nerve, and has been seen, 
in the jiostcrior triangle of the neck, to divide into sii]H!rticial 
cervical and ]K)Btcrior sca]>ular bmnclu-s (wIkmi the latter does not 
Mine firom the third part of the sul>clavian). The Trtinscersc dcrvical 
win opens into the external jugular. 



1. AuricuUr anaatomous. 

I* Poftrrior auricular. 

1 Anterior cerebral. 

i. OocipiUl. 

4. Anterior communicating. 

4. PHncep* cerricis. 

& Uidille cerehnil. 

7. Poiterior c«rvical anostomoaui. 

8. Ophthalmic. 

9. Stetno-mastoid anastommiis. 

10. Banlar. 

11. Saperficial cerrjcat. 

13. Tenninatinn of rcrtcbraL 

13. Deep cervical. 

14. Uiddle temporal. 
a. Posterior acapular. 
18. Transvene fui'ial. 

17. Superior intercostal. 

18. Temporal. 

19. Supim>Kapular. 

SO.' Intenial maxiUary. 
II. Aemmio-thoraeic. 



'£i. I'lirotid »ud mtuwturK'. 

23. Tliiintcii'. 

24. Knciiil. 

'25. KubiH'apulttr. 

26. Linxuiil. 

27. iSniptilnr anastomoain. 

28. Asoendiiis plinrynKenl. 
2'.), IntiTi'cMtiil iinun'toinosU. 
:J0. SH|M'riur thyroid. 

S2. Vcrtci.nil. ' 

.'14. Thyn>id iiniistomoM-s. 

'Mt. Iiif<Ti"r tlivruid. 

3S. Tmchciil iindirsopliiiKcul. 

40. Origin of vertrbml. 

42. Tm< liciil and n'sopliiigral onaatn. 

nioae.i. 
44. Intenial mnmmnrv. 
40. Traclieiil and a>Bophsgeal branches 

of nnrta. 
48. Innominate. 
£0. Aortic inlerrostaK 



456 



THE SIDE OF THE NECK. 



The ajtery is fretiucntly of small sue or nltoyellier WMidng,! 
the jKislerior scapular or the transverse cer\-icnl iiwlf may 
from the third, ur sonietiiues the secinid, part of tlie suhcluvian. 

e. The Supra-xctipHlur artrry run» i>utWrtrd in front of the stalrn 
anticiiB, the phrenic nerve, uuil the thin.1 portion of the siilicUril 
artery, iiiiniediiitely behiml the chivicle, and has been fcoon in 
posterior triiiiigle of the neck. It gives olf atirmo-tnculukl. tuji 
sternal, clavicular and snpra-atromial limucheii in the neck, und I 
:^niiill Kithacapiiliir branch at the upper bonier of the acajiula ; 
patses iiver the tiunsverse ligament of the Hcupula to supply I 
supia and iufra-Kpinous I'ossa; (p. 42), The Supra-«e<iptUar rem op 
into the external jugular. 

The Second Part of the Subclavian Artery (Fij:. 5ii-5, ij 
is placed lieliind the scalenus anticus, and has the sutue relatiimn i 
both sides of the body. It is related in front to the platy^juii, t^ 
cervical fascia, the clavicnlai' origin of the stenio-niast<iid, and l 
scalenus anticus, and behivtl to the apex of the pleum, the «aleiu 
nicdius, and the ascending jiart of the first dorsal ner\r. AIot«\ 
are the cords of the brachial plexus, and bduw is a sninll portion ( 
the inner Iwrder of the first rib.* The enbiiacian nin I•^ helo 
the level of the artery at this pf)int, and separated from it by i 
scideuus anticus. The only branch of the second part of the fli 
clavian artery is the superior ititcrcontal artery on tlie right side, 
left artery usually arising on llic inner side of the anterior s'-aleua 

The Superior Intercostal Artery (Fig. 206, 7) springs fn 
the posterior part of the superior border of the subclavian abonf 



Fig. 208.— Distribution of the iiinlh, tenth aud fli-smth nenre* ol 
tlio riglil side (from Hirsrhfold Hnd Lcveille). 

14. Superior laryngeal nert*. 

111. Intomal carutid. 

IB. 'riiyro-hjoidfuii. 

17. ExitMTial L-arotid. 



1. 
2. 
3. 
4. 
6, 
6, 
7. 
8. 
9. 

10. 
11. 

12. 
13. 



Poslfrior auricular artery. 

Temporal lulcry. 

Occipiuil itrterj'. 

ClobBii-pliarjugcal nenru. 

6. Kpiuid-aci-eMory nerve. 

6. I'neumo-gngtrie nerve. 

StATntf-mastoid (cut). 

Fociiil artery- 

Hj pDfili'ssal norvi' with rommuni- 

cation from 2nd ccrvicjii nerve. 
Lower end of ditto. 
Superior cervical gtmglion of 

sympathetic. 
DiKa*tricus. 
Thud cervical nerve. 



18. Common cai'otid. 

19. Fourth cervical ncr»e. 

20. Inferior constrictor of plmiTin. i 

21. Phronii^ nerve on soal^ius anticiiC 

22. Crico-thyroideus. 
2:t. Middle cenical gmigUoo, 

24. Trachea. 

25. Thyroid a^i*. 
2<i. K»' ' viis-eal nerve. 

27. Su: -ry. 

28. Inn .; UTy. 



* Tile phrenic nen'e ia commonly (riven lu ooe of the anterior mUtiiim il j 
this port of the artery, but it reaihea the iuner border of the scalenus abort lite] 
vessel, and crosses tho first part of the subclavian. 



THE PNEUMO-OASTHIC NEKVE 467 

Fie. 208 




1, (bophagus. 

K T«Da cava aaperior (cut). 

I. OangUiled cord of (ympathctic 

I Vmbenor puJmonary plexut. 

. Pbnaic aem (rut). 




3.5. (iOsophRf^pnl pU-xuii. 

37, Venu a/.ygtm iniijur. 

''til. Thoracii' duel. 

■1). Thoracic aorVu. 

^3. Urent splnnAnic ntrve. 




4.i8 



THE SIDE UF THE KECK. 



tliird of an incli external to tbe origin of the vertebral. It 
upivardt for ii fliort diftljince niul after diviiling into two linuidu 
tljo Jirnt intr.ritutat ami llie deep ctrricul, tiet-cenda into tbr thorax a 
fripiit of the neck of the tirat rib, giving branuhes to the first inur- 
cof-lal fepaee, iinil unoxtoiiiiigitig with the upptr iliU.ica»tal luntij 
fnmi tlie uoitii in the Hecoiid g]iacc. The intercoitai bniiich, bauds 
su]i]ilyLiij; the first and second inten-ostol s})aceB, given olf ynUnar 
njiiiiiil anil miucuiar braiulus ufter the nioiincr of the nortic inliir- 
costulrt. Tlie drep errvical hramh passes upwards nnj Imdiwarii* 
U-tween tlie first rib and tlie transverse process of the newnlii 
cervical vertebra, to be dLstributed to the inuscle* of the ini.tij 
refjion, and to aniistoniote with the princejw cervicis of the onij 
and nuisr.ular branches of the vfrti'bi'ul between the coiupleitu uid 
iteuii8])iuiiliii colli. 

The Sujirriur Intrrcoittal J'rin opens into the innominate vein 
the left side, after crossing the arch of the aorta and comuiiuiicatiii|f' 
with the left upiier azygos vein ; on the right side it ends in tin 
vena azy^jos major. 

The Third Part of the Subclavian Artery has liet-u Jiaieatd 
ill the pdsleiior triangle nl the neck (p. -U7). 

11ie Subclavian Vein is the continuation of the u.\illarv t< 
and has lietn seen to lie anterior to but below the level of it* u: 
It piiBiics over the f'l'oove on the first rib in front of the scaleiii 
anlicus ; ami i-uns in front of the apex of the pleura and a Uti 
below the tii-st jiait of the nrteiy, aiiil joins the internal jugular v 
to form the innoiuinate. Tbe thoracic duct iipen» into the I 
suliclavian vein close to its junction with the internal jugoli 
and the right lymphatic trunk occupies a similar position ou 
right side. 

Tribitlariet. — Tho txtimal juijular vein terminates in the »i 
clavian on the outer side of tbe scalenus anticus, and the i' 
vein usually joins it while it lies upon the fii-st rib. TJio vei 
and anterioi jiij,'ular occasionally ojieu into it. 

The Thoracic Duct may be seen, on careful diKsectiou, risingat 
high as Ilie lower border of the seventh cervical vertebra, Ihi 
crossing ln-binil the carotid slieath and in front of the vertjsb; 
artery, the tirst stage of the subclavian artery, and the phrenic nei 
to enter the sulichivian vein as above stated. It is closely rel* 
to the lowest of the deeji cer\ical glands, and is eudiingercd ilurii 
the operation for the removal of these. It is sometimes double, 
conveys the whole of the lymph of the body, with the exception 
that passing through the riglit trunk. The Right Iiymphsl 
Trunk drains the right dide of the head, neck, and chest, tlie rigl 



4 

.1- ^ 




THE PNEUMO-GASTRIC NEUVE. 459 

pleuia and lung, and the right side of tin- tirnrt ; and tc-rniinateii in 
the right Bubclavian vein. 

The Fneomo-gMtrio Nerve (Figx. ioH & :>()9) (lOtli nervi!) 
is only seen in its cerviuid (lortiim at ]iii-Kcnt. It is unclimuil in u 
leparate compartment of tliu uarutid Hhoiith, lyin<; between und 
liehinil the jugular vein and common cunitid art<T.v, mid eiitem the 
iuperior aperture of the thonix on th<t inner »id(! of tlie phi-etiii- 
nerve, paKsing, on the right Hide, In-lwecn the Huboluviun artery 
and the innominate vein, and on the left side between the eoninion 
carotid and subtdavian arterieH, and behind the innoiiiinatv vein. 

Its *'wy*;rior iMrtjuii-iil brancli f 1 4 & y; njirings from the ganglion 
of the trunk below the Jugular foranien, and riinuiug liirwurdc 
Iteneatli the internal jugular vein and internal earotid artery, a]ii>eari- 
oppoxite the hyoid Ixme, and ]>ierce» the tliyro-hyiiid nicnibrane to 
^apply the mucous membmue of the larynx. Itcfon; entering the 
Innrnx the nerve given a small rxlrrtinl liiniiiiiiiil braneh, which 
nins ob]ii(Uely downwanU, along the upper border of the inferior 
i"oiistrit:tor and beneath the stenio-thyroid nniw.le, to KU])i)ly the 
crico-thyroiil, one of the intrinsic muKcles of the larynx. It give» 
otr alKO gome filaments to the inferior con^tril'tor and sometimes u 
KHiall canliac branch. 

The Iknirrent Lannigeal AVrir (26 & 2 1 ) Cinferior) is seen run- 
ning upwards along the side of the trachen, iHitweeii tiiix and the 
u-aophagus, and after ]Hu<!>ing under cover nf the lateral IoIh- of the 
thyroid bisly, diHa]i]:ieai-s lieneath the biwer border of the inferioi- 
constrictor. It lies suiHTlicial to the liganientmis band wliie.h fixes 
the lateral lobe of the thyroid ImmIv to the up]ier tracheal riiig« 
before passing beneath the constrictor, and it is heit! that it might 
be wounded during ablation of the bcMly unless care is exen'i-'eil 
(Fig. 211). Its amriie ditlers on the two siiles of the boily ; <in the 
right it arises from the pneumo-ga-stric in the neek, in front of the 
subclavian artery, and winils Istlow and then behind the vessel ; on 
the left it arises in the thorax, and turns in like nianner mund the 
arch of the aorta extcnial to the duetus arteriosus. It gives ofl 
cardiac, tracheal, and (esophageal branches and twigs to the inferioi 
constrictor, and supplies all the intrinsic iiiusoles of the larynx 
except the crico-thynnd. It coniiuiinicales by a small tilameiit 
with the superior laryngeal. 

The Cardiac (17) branches of the pneunio-gastric are mipiriiir, 
given off high in the \vp\>eT ]>art of the neck, and Joining the sym- 
pathetic ; and inferior, arising a little above the u]i]H!r )>]H;ning of 
the thorax, through which they pass to Join the canliac ])lexu.ses. 

The Pharijngeal bnincli and some small rntiiiiiuiiicdtimj bi-anches 
taidag at the upper jmit ot the nerve ftre not yet visible. 




THB SYMPATHETIC NKUVE. 



4G1 



The HypoglooBal Nerve (Fi}{. 208, 9) (ISth m-rvcj after coni- 
mtinicating with the fint cervical uervu lunl superior cervical 
gaD};lion appears helovr the {HMtcrior bvUy <>f tlic diffostrir iiiiucle, 
hookin;; ruund the stenio-miiMtuid artery, and rurving forward 
Auperticially to the great veiwels. It afti-rwanlii ]Nu<i)es iM-nciith the 
stylohyoid and posterior belly of the digaxtriciia cIum; to the hyoid 
lione, and is then seen in tliu angle Iwtweeii the tw<i bellioH of the 
dij^tric muscle, lying upon the hyo-<,'losj(U!> Ih.-Iow the liii);ual branch 
of the fifth ; finally disappearing' lieneuth the ])oKteri()r border of 
the luvlo-hyoid muscle to supply the muscleti of the tongue 
(Fig. 209, n). 

Its lUteetuKnij bnitu-h (rauius descendeiis cervicin) arii<eM ojtpoxite the 
occipital aiteiy, and runs dowiiwanl und forwanl either ujtoii or 
within the carotid slieuth, to supply the stenio-hyoid, stenio-tliyroid, 
and ouio-hyoid muscles, and to fonu u loop (tinmt lii/piviliMiii) with 
one or more branches from the Slid nud 3nl nerves of the cervical 
plexuB, the eommunieanint etrviei* (Fig. 2ii4, 7). 

The Htm to the Ihijro-hyoid miufle is a very delicate branch given 
off from tlie 12tlt nerve just jjefore it pusses Ix-ueath the dignstric. 
This and the last as well its the branch to tlie geiiio-hyoid ure to 
be traced to the communication frcjm the 1 xt cervical uer\'e. 

The Sympatlietio (Pigs. 2i)H & 2(i») in tlie neck lieslHthind the 
carotid tlieath upon the prevertebral muscles. It is a slender 
greyish cord bearing three cervical ganglia, of which only one can 
now be seen. 



3. Pbaiyii^I brnnch of pneumo- 

gaatne. 

4. GIoiw>-pharyng«il nerve. 

5. Lingual nerve. 

6. Spinal-aeecMoiy nerris, 

7. Middle ooBitrictor of pharynx. 

8. IntenuljugoUrrein (cut). 

9. Sapmior larrngeal nerve. 

10. Ganglion of trunk of pncumo- 

gartric nerve, 

11. HypogloiMd nerve on hyo-gliHWiiH. 

12. Ditto commuDiniting with npiniil- 

■eeemryandfintcrrvicalncrve. 

13. External laryngeal nerve. 

14. Second cervical nerve lotiping 

with first. 

15. Fhaiyngeal plexun on inferior 

eoDitrictor. 

16. Superior cervical gnnglion uf 

sympathetic. 

17. Superior cardiac nerve of pneumo- 

nstric. 

18. Thud cerrieal nerve. 



I'J. 
20. 
21. 



23. 
21. 

2i5. 

2f.. 
27. 
28. 
2!t. 

:«). 
:il. 
;t2. 

■•{3. 
34. 

an. 

36. 



Thyroid Ixnly. 
Fourth iTrviriil nerve. 
21. l>'ft rt'i-urri'iit hiryiigeul nerve. 
8|)inal-iU'(eKi«irv rinninunieutlnK 

with cervicuf nervi-H. 
Tnichiii. 
Midille cerviral pinirlion <if ayin- 

pathetic. 
Inferiiir ciirdiiir nerve of pncuino- 

gantric. 
1'hn'iiic nerve (cut). 
Ix^ft <'nn>tiil iirtery. 
Ilruchiiil jilexu-H. 
I'hreiiic nerve (cut). 
Infi-rior cerviiiil ganglion of syiu- 

nathetii'. 
rulinonary plexufi of pncunio- 

^latriv. 
Thoracic aorta. 
(Kaniihugeal |iU-xus. 
Vena azygos Huperiur. 
Vena axvgox minor. 
Gangliateil cord of sympathetic. 



4(5* 



THE SIDK OF THE NECK. 



The middle rervtcal or thyroid tjanglion (23 & 24), 
ami often scarcely distinguishalile, lies opposite the fitU cenic 
vertelira, and usually over the fimt loop of the infeiior tliv 
artery. From this gaiigliou Ijifiiiclies of commujUeiUiou jw to 
tifth and si.\lh cen'ieal nerves ; lUyroid branches urw distribul 
upon the inferior thyroid artery ; and the muldU cardiac nfrxt (tli« 
dee]) or great cardiac nerve) parties into the thorax, communin 
injj with the recurrent laryngeal nerve to form the anta Vitaurn 
(FiR. 210). 

The Spinal Accessory Nerve (Fig. 20rt, 5) (Uth nen'e) 
passing geiiendly superficial to, sometimes Ijoneath the iiiteni 
jugiilai vein, ap|Hjars below the dif;a»tric muscle and cr<>**-« onr 
just lielow the extremity of the transverse process of the utW 
])ierce» the deep surface of the stenio-mnstoiil muscle, givi 
branches to it, and then cross*-* the jxjsterior triangle, riiiuiiiin iif 
the levator anguli scapula; to reach the trai>exiii8, which it supjA: 
In the gte mo -mastoid it couiiuimicaf«8 with the nerve fn^m 
cervical plexus to that muscle, and in the posterior triatigle 
trapezius it is joined by braucbes from the third and fourth ccrvi 
nerves. 

The Cervical Plexus (Fig. 204) is formed by the ontei 
branches of the four u])i«t cervical nerves, but the loop from tr 
1st nerve to the 2nd is of very small size, and cannot 1«? well 
in this stage of the dissection. The 2nit, SnI.and Uh nerves api 
between the ivctus colpitis niiticus major and the middle scalen 
lying l>eneath the sterno-mastoid. Each of ihese ner\-es conimui 
cates with the one above and below it, and gives olf sii{>erlicial 
deep cervical branches. The superticial branches of the cervii 
plexus liave been nlrwidy dissected in the jjosterior triangle, 
can now l>e traced to tlieir sources, — the great auricular, w 
occipital, and 8U])crficial cervical bnmche* to tJie 2iid and 
ner\'es, and the descending branches to the 3rd and 4th uervw. 

The deep branches of the ci-rvical plexus are — 

1. CommHuicatiiig branches with the 9th, 10th, and I 
cranial nerves and the sympathetic. These will aftcnvanU 
dissected. 

2. Mittcnliir braiiclu'jt, parsing forwards to the rectus capitis ontici 
major, rectus minor, and rectus lateralis (from the 1st) ; others 
directed backwanls, and go to the sterno-niastoid (2nd), levator 
anguli scapulas (3rd), trapezius (4th), and scalenus niedius (3b1 
and 4tli). Those to the stcrno-mastoid and tlie Irapexiaa emtr 
municate willi the spinal accessory nerve. 

3. The Communiainttt C'enncts (7), usually consisting of t»o 



THK PHUKMC NEKVK. 



4<>:i 



bo" frotn iLi" StuI and .Inl iiffn'cu. Tliry join the ileiic«u<Wiii) 
■< bruucli I'f till- hyiioi^lfwifcftl t/i form thi* hiimh liyput^loiui, urnl 
a bmticli to tliw j«wUTior hfJIy of tlie oino-hyoiij. 
iTho Pluruie tierpt (ii) ariniii); from the 4th tiervn (or from 



Fijf. 210. 



% s a a 



s 



aiul cuotjil 



■tlhtmrti 
1 bfftttcU 



llrau'h 



I to \mTir'\m\ »rtrrv 



hcmlimr unw . . - 




Ut (.'crvlcitl iiiTvn. 



_|»1 ami 4th) roceiveo u Imuich of cunuiiunicaliuii from the 0th, 
rtlltf «luwiiWftr>lH ii[Hiii thii Hcak'iiua iinticim, gcttiii;^ to iu iiiiiiT 
ler itt tlie It^iwor purt uf the neuk. It then ctossea in front of thu 



L— Dia(nm of the iuperior, luMdlA, »ni infrriiir serrioa] ganglia of the 
•)rm{uitlir^lii: (dnwn liy J, T, Uruy). 



464 



THE SIDE OF THE NECK. 



iirat stage of t)ie aubeliivinn artery and tlie i-oot of the internal nu 
inary artery niul beliiiid the innoininiite vein, to enter the thunu. 
conimunicate.s here with the synij^iathetic, and abn, ^<iumtJy, rid 
tlie nerve to the suliclavius from the brachial plexus, anil will tvhtt-' 
quently be traeefl to the tliajihragiu in the Jianection of the thorn. 

The Trachea i» now sulliciently exjiotsed for thf exaiuiuaiiun of 
its i-elatioiiB in the neck, but its structui-e niu«t l>e studitil Istcf. 
It ii" about 4.^ inches in length and extends from the lower liii ' r 
of the fiixth cervical vertebi-a to the lower border of tlic f.nj •], 
doi'sal verteln-a, where it bifurcotea into the bronchi. It 'u loii^ii 
during the act of deglutition, and during the proiUu'tion of hijjli min 
ill vocali.«alion, owing to the wider sepamtiou of its component riqiii j 
by the elevation of the lan-iix, and it is also stretched to 
extent when the cervical vertebno are extende«l. 

In front of it in tlie neck lie the isthmus and pyramidal lob* i 
the thyroid body (usually over the uj)per three rings), tlic tli?n> 
hyoid and Bterno-thyroid muscle.s the cervical fasciic, thr m\\\kx put 
of the renuiins of the thymus, the inferior thyroid veins, anil the 
thyroidcn inia artery when this vessel exists. Lnirrally it is i 
close relation with the lateral loVies of the thyroid Ixvlv, uml I 
recurrent larj-ngeal nerves run in a groo\c on each side between it: 
and the a;sophiigus. Posteriorly it is attached by connective tia 
to ihe anterior wall of the (esophagus. It is invested by a cnnnco 
tivc tissue sheath. 

The (Esophagus also commences at the lower liorder of the 6tl 
cervical vertebra below the lower border of the inferior con^trictorj 
anil passes into the chest after a very short course. In the neck i 
has 1/1 frwtt the trachea (projecting somewhat beyond it on the Itfl 
side), the thyroid body, the left recun-ent laryngeal nerve, and ihclefl 
common carotid artery. Behind are the vertebiw and the lung 
colli, and on the left side is, in addition, the thoracic duct Thf 
cinreut laryngeal nerve runs in a groove between it imd the tmrha 

The Thyroid Body is a solid ductless organ embracing (he (mil 
and sides of the trachea. It ia composed of two lateral lobes con 
necteil by an isthmus. The i«(AmHx is half or three-quarters of i 
inch in depth, and lies opposite the tirst dorsal vertebra, in front i 
the second and third tracheal rings and behind the stemo-hyoid t 
stenio-thyroid muscles and anterior jugidor veins. It ia commonlj 
crowned with a small process of glandular tissue culled 
pyramidal IoIk,* which stretches upwards a little to the htl i 
the middle line towards the hyoid bone ; and it occasionally rectiv^ 

• The pynuniiinl lobe probably represents the lower part of the thy 
duct, a fa'tal tulic at nnti time o\wmng ivt llw totuoni coecum of the toDgtu. 



TUK TUYROUJ UODY. 



405 



ling tn it from the hyuid bune, and knuim 
rnt/ST tjtaiuluUr thifrviilnr. Tbi? liUrnil Mvt an about two 
length, 8oiiicwhul cuiiical in I'uiui, with lluir iipici-a 

Pig. 211. 




r, iMkI lii' by the »iJ<;» of the trnohi'it from ihi; U:vv] of the 

lilur<al rerti'btn tu the luwir purl of tlic ulu of tlit; tliyroid 

I ; Quiy tixtenJ farther above than bfh)w- the Uthmua. Kiicb 



Pig. III.— Tlie thjToid body and ila mlotioiu (W. A.)- 



rutlil orlvry, firing off 
iaT thyroid briDoh. 

Lid art«r} . 



nnirntl*. 
itm fnrwanl* 
I Gcamcntof iht-noid body. 



tl. ('rtcNijil rtirttUifii. 

rj. Vert.'tinil «rt.TV. 

13. ICcriirri'nt lurynxral nurr*. 

14. Inforior thyniid m-ti'ry. 

It*. 'I'lniiivdmilU colli iirlury. 

17. Tni.li.A 

18. Siiji. rTiiry. 
1!». Con. I \ 

■jn. Su|ii ,..,,.,, „,,.,,. 

'."J. luteniul iiKLiumiiry nrtery. 
H H 



466 



THE KACE. 



lobe is ill rektion ajiUriorly with the sternohyoid, iteroo-UiTl 
onio-hyoiil, uiul sU-ntoiiiostuid muacles, the anterior jujfiilar vi-in,! 
the iiilc'jjiimcnl iiml fnsr.ue ; jwnlerutrl j/ with lL« limjjiis colli, ami f 
comiiioii carotid (slightly), inferior thyroid, and \ertel)nil nrt«B 
i»tcnia//i/ with the lower pftrt of the larynx and phurynx, the trad 
and ccsophagus, and the recurrent laryutjeul nerve ; rrtcrnallij wilk 
the carotid sheath. \l» Imijx approaches the dome of the pleura, uvl 
it* iijitj: lies uj>on the inferior constrictor by the side of the cric<)i<J 
and thyroid cartilages under cover of the »tenii;>-tliyit)id. The \ 
or^an in invested by a capsule, which is connected above with a ( 
penmry liijamriit running from the isthmus to the Ixjdy of tlie hf« 
bone, and at the sides with lateral ligavienii, which are attai-Lwl I 
the estivinities of the tii-st iinil second tracheal rings, and son 
times to the lower jiart of the thyroid cartilage. The recur 
laryngeid nrrves run upon the latter. 

It is ubiuidontly supplied with blood by the superior unJ infm 
Uiyroid arteries of each side, and occo-sionnlly by on odditioi 
branch, the OnjroUlea ivm, which may come from the innomiuil 
the right common cai-otid, the aorta, or mort rarely, from tlie rigl 
iiitenial niannuary or right subclavian. The arteries freely luu 
inose in the substance of tlie body, anil reliini their bloml by tbn 
veins on each side, vh., the superior and middle thyroiil, which jiii 
the internal jugular vein, and the inlVjior thyroid, which may lie Iracd 
down the front of the trachea to the iunominato vein. lt« 
gupjily is deriveil from the superior and middle cervical gangli/i. 

The thyroid biMly is composed of numerous closetl vesicles an 
taiuing u yellow fluid. Supplementary thyroids are not infn 
quenlly fouud in the neighbourhood. 



The Kale. 

The face is a region iu which it will be convenient to out* 
different dissections on the two sides, i.e., of the musclw tad 
ves.se]s on one, and of the nerves on the other ; and the diaSMtw* 
are therefore mlvised to adopt this method of proceeding. 

Before commencing the dissection, the student should observe th^ 
external anatomy of the eye and its apjpcndages, so tliat these m»* 
be seen in a.s natuml a comlitiou us pos-tible (Fig. 212). 

On the margin of the orbit is the ituprrcitium or eyebrow, a iU(^ 
of thickened skin covered with hairs. The eyelids or fnilfi'lmt ai» 
two thin folds composed of a ileiise fibrous tissue (the 8o-calle»l lurutl 
cartilage), and of nlUl^clc and fascia ; covered externally by lhe<lu) 
and lined interuull y by the conjunctiva palpebmnim continaMlf 




THE LACUYMAL APl'AKATUS. 



4»i7 



rarfoce of the eyeball. The points of junction of the two lid« 

called the inner and outer rant hi, ami alon^r the free borders of 
' lid* will Ije »cen the fUia or eyelashes, which curve upwards 
m the upper, and downwards from the lower lid. 
Before opening the lids they shouhl Ix- drown forcibly outward 
raids the temple, in order to 
ikc tense and prominent the 
tie Undo oeuli or intemnl jtal- 
iral ligament by which tlieir 
DM extiemitici) are attached 
I the nural process of the xii- 
nior maxilla. A smaller and 
« distinct actrrnal pali)eliral 
futent passes from the outer 
ttianities to the frontal procesg 
t the' malar bone, at the outer 
dge of the orbit. 

Hie margins of the li